MAPP Program Manual - Nicotine Dependence Clinic

Transcription

Cover
Placeholder page, not for print
Mental Health-Addiction Services-Public Health Program
Program
Manual
Live.Healthy.Positive.Change
Tab Introduction
Introduction
Beginning.Assess.Goals.Support
Table of Contents
Overview.............................................................................................................................................................. 1
Funding...................................................................................................................................................................................................... 1
Reproduction........................................................................................................................................................................................... 1
Citation....................................................................................................................................................................................................... 1
Declaration............................................................................................................................................................................................... 1
Acknowledgements.............................................................................................................................................................................. 1
Executive Summary........................................................................................................................................... 3
Rationale.................................................................................................................................................................................................... 3
Background.............................................................................................................................................................................................. 3
Purpose...................................................................................................................................................................................................... 4
Clarifications............................................................................................................................................................................................. 4
MAPP Program Organization........................................................................................................................... 5
Target Audience...................................................................................................................................................................................... 5
Communications With Other Health Professionals.................................................................................................................... 5
Budget........................................................................................................................................................................................................ 5
Staffing....................................................................................................................................................................................................... 5
Referral Process....................................................................................................................................................................................... 5
Facilitators................................................................................................................................................................................................. 6
Training...................................................................................................................................................................................................... 6
Location..................................................................................................................................................................................................... 6
Transportation......................................................................................................................................................................................... 6
Resources.................................................................................................................................................................................................. 6
Evaluation................................................................................................................................................................................................. 6
How to Use the Manual..................................................................................................................................... 7
Format of Program................................................................................................................................................................................. 7
MAPP Approach...................................................................................................................................................................................... 7
Pre-assessment and Referral.............................................................................................................................................................. 7
Sessions...................................................................................................................................................................................................... 7
Nicotine Replacement Therapy (NRT) or Pharmacotherapy.................................................................................................. 8
Peer Support............................................................................................................................................................................................ 8
Follow-up Support Group................................................................................................................................................................... 8
Table of Contents
Mental Health-Addictions Services-Public Health Program
pg. i
Session 1: Healthy Living..........................................................................................................................Tab 1
Patient/Client Weekly Checklist
Handouts
6 Steps Towards Healthy Living
Caffeine
Why Do So Many People With Mental Illness Smoke?
Key Questions
3 Deep Breaths
Deep Breathing Exercise 2
Session 2: Benefits of Stopping...............................................................................................................Tab 2
Handouts
How Does Tobacco Advertising Affect Me?
How Much Does Smoking Cost?
Diary
Reward Yourself
What Are My Smoking Patterns?
Session 3: Smoking and Your Body.........................................................................................................Tab 3
Handouts
Nicotine Addiction
Why is Smoking Dangerous?
Chemicals Found in Cigarettes
Changes Your Body Goes Through When You Stop Smoking!
Save Your Smile… STOP SMOKING
Your Personal Benefits of Stopping Smoking
Session 4: Nicotine Replacement Therapy & Pharmacotherapy........................................................Tab 4
Handouts
Life Without Nicotine
Nicotine
Nicotine Patch
Nicotine Gum
Nicotine Lozenge
Nicotine Inhaler
Nicotine Mouth Spray
Varenicline
Sustained-Release (SR) Bupropion
Better Coping Strategies
What Happens When I Stop Smoking Without Pharmacotherapy or NRTs?
What Can Help Me Stop Smoking?
My Questions About Nicotine Replacement Therapy and Pharmacotherapy?
Table of Contents
pg. ii
Session 5: Getting Ready to Stop Smoking...........................................................................................Tab 5
Handouts
What if I Am Not Ready to Stop?
Sample Goodbye Letter
It is Possible for Me to Stop Smoking
Is It Worth It?
Session 6: My Stop Plan.............................................................................................................................Tab 6
Handouts
Making the Decision to Stop
Suggestions
Life as a Non-Smoker
I Will Set a Stop Day
My Stop Plan
Planning for My Stop Smoking Day
Session 7: Withdrawal................................................................................................................................Tab 7
Handouts
External/Internal Triggers Group Activity
Triggers are Different Than Cravings
Coping With Withdrawal/Recovery Symptoms
Becoming a Non-Smoker – What’s in It for Me?
101 Things to Do Instead of Smoking
Triggers and Cravings
Session 8: Changing Negatives Into Positives.......................................................................................Tab 8
Handouts
Changing Negatives Into… POSITIVES
Pressures to Smoke and What to Do?
Session 9: Stress..........................................................................................................................................Tab 9
Handouts
What is Stress?
The Stress Response
How Do Cigarettes Cause Stress on the Body?
Positive Changes Your Body Goes Through When You Stop Smoking
The Relaxation Response
How Can I Manage Stress?
How Can I Manage Stress? (Flip Chart)
Exercise: Deep Breathing
Table of Contents
pg. iii
Session 10: Stress Relief..........................................................................................................................Tab 10
Handouts
The AAABC’s of Stress Management – A Decision Making Model
Stress-Busters – Activities to Beat Stress!
Tension Releasing
Why Do I Smoke? Tips to Help Me Cope
Session 11: Being Active..........................................................................................................................Tab 11
Handouts
Activities to Get You Moving
50 Ways to Make Physical Activity Part of Your Life!
Stretching Helps Your Body in a Variety of Ways!
Session 12: Healthy Eating......................................................................................................................Tab 12
Handouts
Healthy Snacks for Adults
Nutrition Tips When You STOP SMOKING
Smoking: If You Quit, You Don’t Have to Gain Weight!
Causes of Weight Gain and Strategies
Canada’s Guidelines for Healthy Eating
What is Caffeine? Is It Bad for My Health?
Food Sources of Caffeine
Five Health Benefits of Clementines
Session 13: Coping With Pressures to Smoke......................................................................................Tab 13
Handouts
Coping With the Pressures to Smoke (The 3 A’s)
Steps to Cope With the People, Places and Things That Tempt Me to Smoke
Saying NO to Cigarettes
Setting Up a Support Team
Cigarette Refusal Skills
Say No Thanks!
Session 14: Slips and Relapse.................................................................................................................Tab 14
Handouts
Dealing With Setbacks
Slip or Relapse
Table of Contents
pg. iv
Appendix A - Resources
Session 1
Why Treat Tobacco Addiction
Top 10 Myths About Tobacco Cessation in the Mentally Ill
Mental Illness & Smoking – Key Messages for Patients and the Public
Mental Illness & Smoking – Key Messages for Health Care Providers and Policy Makers
Carbon Monoxide Monitoring in Tobacco Dependency Intervention
Session 2
What About Smoking ‘Light’, ‘Mild’, ‘Smooth’, ‘Gold’, or ‘Silver’ Cigarettes?
Session 3
Contraband – The Facts
Session 4
NRT/Pharmacotherapy Average Costs
Questions & Answers – E-cigarettes
Algorithm for Tailoring Pharmacotherapy in Primary Care Settings
Session 6
Self-Help Kit
Session 7
Walking on a Beach Guided Imagery
Four D’s
Session 8
Lemon Guided Imagery
Sample Responses for “Pressures to Smoke and What to Do?”
Session 11
Physical Activity & Smoking – Key Messages for Patients and the Public
Session 12
Oatmeal Buffet
Session 14
Ending the Group
Appendix B - CO Monitor
Session 1
What is Carbon Monoxide?
Client – Frequently Asked Questions (FAQ)
Quick Start Guide for Operator
Carbon Monoxide Detector – Ordering Information
Appendix C - Forms
MAPP Assessment Form
Letter to Health Professional
Confidentiality Agreement
Pharmacist Form
MAPP Overall Program Evaluation
Certificate
Appendix D - References
Table of Contents
pg. v
Overview
This manual has been developed by MAPP (Mental Health, Addiction Services, Public Health Project) staff of
the CEHHA (Colchester East Hants Health Authority) and PCHA (Pictou County Health Authority). The MAPP
program is intended to guide coordinators and facilitators through a smoking cessation program for those
living with mental illness.
Funding
MAPP has been made possible through a financial contribution from the Health Canada, Tobacco Control
Programme, Grant and Contribution program.
Reproduction
Reproduction of the MAPP Program Manual is permitted for educational and non-commercial purposes, in any
form, including electronic form, without requiring the consent or permission of the authors and/or the MAPP
Project, provided that the following is noted on all electronic or print versions: © MAPP/CEHHA 2013
Citation
MAPP (2013). MAPP Program Manual. CEHHA, Truro, Nova Scotia, Canada [McMullin, Krista; Morse, Neil; and
Skinner, Nancy (PCHA)].
Declaration
MAPP has not received any financial contributions from any pharmaceutical company for the production or
printing of this manual.
Acknowledgements
CEHHA – Colchester East Hants Health Authority
PCHA – Pictou County Health Authority
MAPP Steering Committee:
Angie MacIntyre (Public Health, CEHHA)
Clarie Chafe (Addiction Services, CEHHA)
Irene Gunn (Public Health, CEHHA)
Ivan Drouin (Mental Health, CEHHA)
Jackie Murphy (Canadian Mental Health Association (CMHA))
Krista McMullin (Public Health, Principle Investigator, CEHHA)
Leona Ross (Peer Support)
Lois Walker (CMHA)
Lorene Atkinson (Peer Support)
Nancy MacVicar (Public Health, CEHHA)
Nancy Skinner (Public Health, Satellite
Coordinator, PCHA)
Neil Morse (Mental Health, CEHHA)
Raj Makkar (Respiratory, CEHHA)
Robert Graham (Addiction Services, CEHHA)
Robert Kozac (Consumer)
Sandeep Sodhi (Pharmacist)
Sherry Brander (Public Health, CEHHA)
Susan Henderson (CMHA)
Introduction
Overview
pg. 1
MAPP Project Facilitators:
Cindy Wilson
Dave Demetre
Lorrie Boutilier
Neil Morse
Vanessa McConnell
Peer Support Leaders:
Leona Ross
Lorene Atkinson
Community Support:
CEHHA Mental Health COMPASS (Community Psychosocial Rehabilitation and Support Service) Team
PCHA Community Supports for Adults Team, New Hope
Addiction Services CEHHA, PCHA
Public Health Services CEHHA, PCHA
Canadian Mental Health Association (CMHA) Truro Chapter
Patients/Clients
MAPP wishes to acknowledge the contribution of the project’s pharmacist Sandeep Sodhi. Sandeep provided
consultation at various stages of the project and contributed knowledge, insight and instruction on nicotine
replacement therapy and pharmacotherapy for the MAPP Manual and MAPP Training Module. He was also a
valued member of the MAPP Steering Committee.
Special Acknowledgement and Thanks
A great deal of the content and concept for MAPP was adapted from:
• “A Wellness Approach to Addressing Tobacco in Mental Health Settings: Learning about Healthy Living”
Manual. Williams JM et al. State of New Jersey, Division of Mental Health Services. Revised 2005.
• “Treating Tobacco Dependence in Mental Health Settings” a two day training conference for Psychiatrists,
Psychiatric Advanced Practice Nurses & Other Mental Health Professionals UMDNJ-Robert Wood Johnson
Medical School, New Brunswick, NJ provided by Dr. Jill Williams and associates, 2009.
• Peer review contributions.
MAPP Program Manual Development Group and Support
The Manual Development Group was responsible for the development of the MAPP Manual through review of
the working copy of MAPP used in the pilot project, supporting materials from the Learning about Healthy Living
Manual, Williams JM et al. State of New Jersey, Division of Mental Health Services, and peer review recommendations.
Krista McMullin
Nancy Skinner
Neil Morse
Sherry Brander
MAPP Program Manual graphic design by DG Communications.
Introduction
Overview
pg. 2
Executive Summary
MAPP is a Stop Smoking Manual for health professionals interested in offering a stop smoking program to
patients/clients living with mental illness. MAPP was conceived to bring a group together to implement best
practice to address the unique needs of these patients/clients.
Rationale
Adults living with a mental health disorder have a disproportionately high rate of smoking and related chronic
illness. Many have special needs and require supports to maintain their mental health while overcoming their
nicotine addiction. Tailored programs specifically targeting patients/clients living with mental illness who
wanted to stop smoking did not exist within the Colchester East Hants Health Authority. MAPP was developed
to meet this gap and provide patients/clients with an appropriate program to meet their needs.
Background
In 2008, the Colchester East Hants Health Authority (CEHHA) wrote and submitted a proposal to Health Canada,
Tobacco Control Programme, Grant and Contribution program entitled Mental Health Services, Addiction
Services, Public Health Services, Project or, hereinafter referred to as MAPP. In 2009, CEHHA was successful in
securing this funding for the MAPP Project until 2012.
MAPP stands for Mental Health, Addiction Services, Public Health Project. It started as a partnership that
formed to support a pilot project to create a healthy living and smoking cessation program for people living
with mental illness. Over the course of two years MAPP was piloted in CEHHA and at a satellite site in Pictou
County Health Authority (PCHA). After a successful evaluation, MAPP was peer reviewed and developed into a
program and manual. It continues to be offered on an ongoing basis within both health authorities.
MAPP content was influenced by a detailed literature search and Treating Tobacco Dependence in Mental
Health Settings, a two day training conference for Psychiatrists, Psychiatric Advanced Practice Nurses and
other mental health professionals. Two MAPP staff attended this training which included discussions about the
Learning about Healthy Living Program Manual. Both the training and manual were created by Dr. Jill Williams
and associates at UMDNJ Medical School, New Brunswick, NJ, USA.
The MAPP Project Team consisted of the principle investigator, team leader, facilitator and co-facilitator.
The COMPASS program (Community Psychosocial Rehabilitation and Support Service), the Community
Supports for Adults Program of the Mental Health Services, CEHHA, played a central role in MAPP including
facilitating group sessions; providing case management services for patients/clients; and was a primary source
of referrals. The COMPASS program provides multidisciplinary services for persons with the most severe
persistent mental illness and/or ongoing severe impairments in daily living.
A MAPP satellite pilot project in Pictou County was offered out of the New Hope site – an out patient
psychosocial rehabilitation program and location staffed by the Community Supports for Adults Team of
Mental Health Services.
Referrals for the MAPP program initially, were received from CEHHA COMPASS team. Once the program was
established, it expanded to include referrals from family physicians, psychiatrists and mental health clinicians.
In the satellite site, referrals were received solely from the Community Supports for Adults Team.
Introduction
Executive Summary
pg. 3
Three patients/clients who had completed the MAPP Program became volunteer Peer Support Leaders.
They received training in peer support, in MAPP (Train-the-trainer), and in numerous other areas related
to addictions, mental health, and group facilitation. They worked with the MAPP Project Team to develop
their role over the course of the project and they provided a range of peer support services to mental health
consumers participating in MAPP. The Peer Support Leaders co-facilitated the MAPP support group, presented
at MAPP educational events, and participated in and presented updates at meetings of both the MAPP team
and the MAPP Steering Committee.
In CEHHA a follow-up support group for those who had graduated from the program was offered.
This group was an open format held once a week where patients/clients were able to continue to receive
peer and facilitator support along with pharmacotherapy. If the support group was not an option for any
given patient/client, the facilitator would see them on an individual basis if they so desired.
Following the pilot project, an external evaluation was completed. The findings demonstrated that the project
was successful in supporting mental health consumers in stopping or reducing their smoking. One of the key
findings concluded that “participant success was supported by the length of the program (14 weeks), the free
pharmaceutical support in the form of NRTs/Champix, the harm reduction approach, and the support provided
through the MAPP sessions and the support group.”
Additional funding was secured from Nova Scotia Department of Health and Wellness for manual development
and provincial training.
Purpose
This manual is intended to be a guideline for use by mental health and addiction providers who work with
patients/clients who live with mental illness and who are preparing to or contemplating stopping smoking.
Clarifications
The term patients/clients is used throughout this manual to reflect the diverse clinical settings where smoking
cessation treatment is provided. The term health care provider is used throughout and is intended to reflect
a broad range of providers in a variety of settings, including hospital, clinic, home care, acute, community,
primary and long term care.
Introduction
Executive Summary
pg. 4
MAPP Program Organization
It is important to identify how MAPP will be organized. Staffing, budget and communication are three key areas
of consideration at the onset. Due to the flexible nature of this program, each organization can decide how to
offer MAPP to meet the needs of their patients/clients with the resources available.
Target Audience
The MAPP program was created for anyone living with a diagnosed mental illness, who is preparing to or
contemplating stopping smoking. Budget restrictions may limit the number of patients/clients accepted via
referral. This should be given consideration and the referral process clearly established and communicated.
Communications With Other Health Professionals
MAPP promotes a team approach with other health professionals in the community. Communication and
collaboration is essential. Establishing a working relationship with other health professionals such as staff from
Addiction Services, Mental Health, Public Health, Pharmacy, Family Medicine and Psychiatry is key to the success
of the program. These partners support patients/clients and may be able to offer support and information to
enhance the program and referrals. Facilitators will find it useful to familiarize themselves with local issues,
processes, and develop a rapport with professionals who support the patient/client on an ongoing basis.
Budget
The budget required for a MAPP program can vary. The main program costs include staffing,
Nicotine Replacement Therapy (NRT), pharmacotherapy, and transportation.
Many organizations can offer staff and administrative support as well as a meeting location as an “in-kind”
donation. Funding for NRT and pharmacotherapy may be available through existing government budgets
for nicotine treatment. Discuss options with your partnering organizations.
Staffing
Ideally MAPP staff would consist of an overall MAPP Coordinator, administrative support and two co-facilitators.
Not all organizations have sufficient resources to allocate. It is possible for the program to be organized
and facilitated by one person with in-kind administrative support. Initially setting up the program and
communicating with other health professionals can be time consuming. An estimate for staff time would
be approximately 4-6 hours per week for group preparation, group session and follow up.
Referral Process
Patients/clients can be referred from a variety of sources including but not limited to family physicians, psychiatrists,
nurse practitioners, pharmacists, mental health workers, public health staff, and addiction services staff.
Determining the number of MAPP programs offered per year and size of each group needs to be established in
order to determine the number of referrals and referral sources that will be accepted. Some organizations may
initially consider recruiting referrals from one source (i.e. mental health services) where patients/clients are also
being supported by a mental health worker. The referral process is flexible and depends on resources available.
Introduction
pg. 5
Facilitators
MAPP has been facilitated by staff who work in nicotine treatment, mental health, public health, and those
hired from the community with a background in working with mental health and/or addiction patients/clients.
A variety of health care professionals could offer the program. The following are essential:
• experience and knowledge of working in both the addiction and mental health field,
• group facilitation experience,
• knowledge of pharmacotherapy and nicotine replacement therapy,
• desire to offer this program to those living with mental illness.
Training
Knowledge and training on the following list of topics would be beneficial for a MAPP facilitator to have:
• Adult Learning Principles (Transformative Learning)
• Group Facilitation
• Peer Support
• Community Reinforcement Approach
• Motivational Interviewing
Location
MAPP sessions could be located in a variety of settings. Consideration should be given to accessibility and a
central location. Most sessions recommend the use of a flip chart. One session does suggest watching a video
clip, which would require either DVD player and TV or large computer screen. Access to a kitchenette/kitchen
is helpful too. A location with these resources or access to these resources would be helpful. A variety of
venues were used in the pilot including hospitals, churches, community centres and Mental Health Community
Outreach Centres.
Transportation
Local transportation and Handi-trans (busing for passengers whose disabilities restrict them from using regular
bus service) are options for some patients/clients. In some areas, MAPP may be adopted as part of an outreach
program of Mental Health Services and patients/clients may be able to have their transportation fees covered
under this program. Gas cards and taxi fees were also provided in some cases and need to be considered in
budget planning.
Resources
Resources recommended for MAPP are optional. The key resource is the MAPP Program Manual.
Handouts could be given in an inexpensive folder or binder. The CO monitor was found to be very popular
with patients/clients of MAPP by acting as a biofeedback tool. Check with your local Addiction Services who
may have one for loan. Other resources suggested are inexpensive options.
Evaluation
It is important to evaluate each MAPP program. The extent of the evaluation depends on resources.
A suggested telephone follow-up survey is included in the Forms Section of this manual.
Introduction
pg. 6
How to Use the Manual
Format of Program
The MAPP program is divided into 14 sessions, offered once a week for 14 weeks, each session lasting
1 – 1½ hours. Sessions could be offered several times a week and the session length changed. Each session
offers a guideline. The curriculum is flexible and content can be adapted. Careful attention was given to the
participants’ progression through the stages of change, and persistent use of motivational interviewing
techniques, allowing individual participation as well as the group as a whole to empower the successful
stopping of tobacco smoking by its members.
MAPP Approach
Mutual respect and support are modelled and encouraged throughout the MAPP program.
Dual group leadership/facilitation is recommended: a lot goes on in MAPP group and there are significant
opportunities for emotional, cognitive and behavioural growth as each patient/client prepares to become
tobacco free. It is an opportunity for people to learn new skills and begin new and improved ways for healthy
living. Staff facilitate shared participant wisdom and experience to guide/encourage each other remembering
to: “let the group do the work”, “tolerating silence”, and seizing “teachable moments” while using MAPP skills,
strategies and resources.
Pre-assessment and Referral
There are options for completing the pre-assessment once the initial referral is received. The health
professional providing the referral may agree to complete the referral and the pre-assessment at the same
time. Another option is for the facilitator to receive the referral and meet with the patient/client to complete
the pre-assessment and answer any questions prior to starting the group program. It is reassuring for the
patient/client to either receive a telephone call or meet with the facilitator face to face prior to the first session
if possible. Face to face assessment of readiness allows for both group participation and individual preparation
for cessation.
Sessions
Each session is intended to be a guideline for the facilitators. The order and length of the sessions, and the
topics are a framework and allow for flexibility depending on each group of patients/clients, time allotted and
facilitator’s knowledge and comfort level.
The manual is divided into 14 sessions, each with sufficient content to span approximately 90 minutes.
How often they are offered and for how long is flexible. Each session focuses on a different part of the recovery
process for tobacco addiction and addresses other behaviours such as stress, healthy eating and activity.
Recommended preparatory resources and readings for facilitators as well as patient/client handouts are listed
for each session.
Introduction
pg. 7
Nicotine Replacement Therapy (NRT) or Pharmacotherapy
In addition to the group sessions, a choice of nicotine replacement therapy (NRT) or smoking cessation
medications (varenicline and bupropion) are funded through the program. Each patient/client interested in
nicotine replacement therapy or pharmacotherapy is encouraged to discuss the options with their health care
provider. Patients/clients are given a MAPP letter to take to a pharmacy of their choice. It is encouraged that
patients/clients use their usual pharmacy where they may have a rapport with the pharmacist. The letter allows
the pharmacy to fill the request of the letter and invoice the appropriate department.
Each letter indicates the NRT that is approved and paid for by the MAPP program and is signed by the
facilitator. Patients/clients must obtain a prescription from their health care provider for varenicline or
bupropion to accompany the letter. Letters are given to patients/clients at the end of each session.
It is encouraged that a letter of introduction to the MAPP program be sent to each local pharmacy by the
facilitator prior to the MAPP Program being delivered.
Peer Support
During the initial phases of the MAPP Project, it was hoped that a role for peer support could be incorporated
from MAPP Program graduates. At the beginning of the third year of the project, we were able to train three
very successful MAPP graduates to become Peer Support. Peer Support are people living in recovery with
mental illness and who provide support to others who can benefit from their experiences. The MAPP Project
was able to send two of our ‘Peer Supports’ to a comprehensive Peer Support Specialist Training by the
Appalachian Consulting Group of Georgia, USA. This training was the first of its kind in Canada and held in
Truro, Nova Scotia.
The Peer Supports are highly valued members of the MAPP team who believe that recovery is possible for
every individual. This particular role for the MAPP Program was developed because of the importance of the
‘lived experience’ with respect to tobacco addiction and mental health illness.
Follow-up Support Group
Our Peer Supports were key team members in both our regular MAPP trainings but also our weekly
Follow-up Support Group in Colchester East Hants. The Peer Supports were able to work individually or in
a group setting with MAPP patients/clients. During this time, they continued to implement their own recovery
plan for their tobacco addiction.
Introduction
pg. 8
Tab Session 1
Session 1:
Healthy Living
Breathe.Free.Increase.Balance
Healthy Living
Introduction of MAPP, the facilitators, and the patients/clients:
• Discuss the importance of confidentially with group members.
• Encourage patients/clients to introduce themselves with their first name and provide appropriate
information that they feel comfortable sharing.
“What is Carbon Monoxide?” (see Appendix B: Session 1: Co Monitor) “Carbon Monoxide Monitoring in
Tobacco Dependency Intervention” (see Appendix B: Session 1: CO Monitor) “Operator, Frequently Asked
Questions”, “Client, Frequently Asked Questions”, “Carbon Monoxide Detector Ordering Information”
and “Quick Start Guide for Operator”. (see Appendix B: Session 1: CO Monitor)
• Explain how the CO monitor works and take individual reading.
Consent Form & Oath – discuss confidentiality of patients/clients and facilitators. Ask patients/clients to sign
consent form and oath. (facilitators can also sign oath) (see Appendix C: Session 1: Form)
Group Guidelines – create group guidelines on flip chart (sample guidelines below). Explain to patients/clients
that these are ways that they will speak and act respectively in a group. i.e. one person speaks at a time.
Group Guidelines (Suggestions):
• We start on time so we finish on time.
• Confidentiality is the key. We don’t use other people’s names when we talk outside of group.
• Stay positive! We don’t use putdowns or criticisms. Let’s encourage each other!!
• It’s OK to “pass” if you don’t feel like participating at a particular time. We want everyone to be comfortable.
• Using “I”. Speak only on behalf of yourself and your own experiences.
• Only one person talks at a time, respect others when they are speaking and they will respect you.
• Please call if you cannot make a session so that you can check in with the facilitator and get an update on
the information you missed. If you miss multiple (3) sessions in a row you may be asked not to return.
• No bragging or nagging if you cut back or stop smoking sooner than others in the group. We all work at
our own pace and we want to support everyone on their own individual journey.
• If you are struggling talk it out!! (Peers, Facilitator, Case workers)
Review “Patient/Client Weekly Checklist”. (Session 1: Handout)
Ice Breaker: Ask patients/clients to introduce themselves by their first name and answer one of the following:
1. Name your birthday month and favourite kind of cake.
2. Name your favourite “just for fun” activity or hobby.
3. What is your favourite TV show?
4. What is your favourite colour?
Session 1
Healthy Living
pg. 1
Break: Reminder of smoking policy for the building and grounds. In Nova Scotia, smoking is not permitted
within 4 meters of windows, air intake vents and entrances to places of employment. Encourage patients/
clients not to smoke during breaks as the smell of smoke on their clothes affects/triggers others and it is a
good idea to practice being smoke free.
“6 Steps Toward Healthy Living” (Session 1: Handout) Group Discussion
• Continue with Mental Health and Recovery Plan
• Healthy food – try to eat regularly throughout the day
• Moving / daily activity
• Find a balance between relaxation & stress
• Keep your health appointments
• Taking control of addictive behaviours
“Caffeine” (Session1: Handout)
• When a person is smoking, caffeine is cleared out of their system faster.
• When a person stops smoking, caffeine intake should be reduced by half to avoid excessive caffeine levels.
• Too much caffeine can give you headaches, upset your stomach, make you nervous and jittery and leave
you unable to sleep.
• Symptoms of caffeine withdrawal can mimic those of nicotine withdrawal.
“Why Do So Many People With Mental Illness Smoke?” (Session 1: Handout) Group discussion. “Mental
Illness and Smoking: Key Messages for Health Care Providers and Policy Makers” and “Mental Illness
and Smoking: Key Messages for Patients and the Public” (Appendix A: Session 1: Resource)
• People smoke for many reasons.
• For people who have a mental illness, smoking can provide relief from some of the symptoms of attention
hyperactivity disorder, depression, schizophrenia and the side effects of some anti-psychotic medications,
but smoking has not been proven as an effective adjunctive therapy for such disorders.
• Smoking has been shown to increase risk of more serious health problems, including the deterioration of
both physical and mental health status.
• People who stop smoking may improve their health almost immediately and save money on medications.
• Some people who live with mental illness believe that smoking helps relieve the symptoms of their illness.
• Biological Factors (Physical/Brain Functions)
• Psychological Factors (Thinking/Feeling)
• Social Factors (People/Places/Things around you or events)
Session 1
Healthy Living
pg. 2
“Top 10 Myths About Tobacco Cessation in the Mentally Ill” (See Appendix A: Session 1: Resource)
“Why Treat Tobacco Addiction” (See Appendix A: Session 1: Resource)
Homework: “Key Questions” (Session 1: Handout)
• What reasons or factors do you feel make you want to smoke?
Thoughts on Naming the Group:
• Ask group if they are interested in giving the group a name and to bring suggestions to next group session.
“3 Deep Breaths” (Session 1: Handout)
• Explain the benefits of deep breathing and demonstrate it for the group to voluntarily try.
• Deep breathing has a calming effect on the body.
• It can increase blood flow which can increase energy.
Session 1
Healthy Living
pg. 3
Supports – Access supports (Mental Health Nurse, Therapist, Doctor, Family, Friends, Smoking Support Group…).
Mood Changes or Changes in Your Mental Health – Contact supports if these have changed or you notice
any differences in your thinking that are a concern or harmful.
Anxiety – Contact supports and try and use some strategies to deal with anxiety (sleep, exercise,
keep hands busy…).
Medication Adjustments – These may be necessary as you decrease the amount of nicotine (cigarettes).
Medication may need to be changed as your body processes more slowly as it returns to normal.
Discuss with health care provider.
Nicotine Replacement – Ask questions, let us know if you have concerns if you are taking nicotine
replacement therapy or stop smoking medication.
Healthy Eating – It is important to drink lots of water, reduce caffeine, and eat breakfast, snacks and
regular meals.
Movement – Increase movement slowly. If physical activity is not in your regular routine, i.e. walk to mailbox,
walk outdoors, around your house or apartment building, dance to a song on the radio, walk for 10 minutes at
a time, slowly increasing your activity.
Process May Feel Abnormal for You – Reducing or stopping smoking may feel very different for each person.
Coming to group will make it more a part of your new routine. It’s a process and takes time.
Reward – Make sure you reward yourself. It doesn’t have to be a big item; it could be having lunch at a
restaurant with a friend, going to a movie, buying a healthy snack or meal at the grocery store, etc.
Replace – It is important as weeks go forward that you replace smoking with something that you like to do
or something you’d like to try, i.e. bowling, knitting, walking, crossword puzzles, puzzles, dancing to music,
reading a book.
It’s Your Journey.
The group is for learning and support.
Session 1
Healthy Living – Patient/Client Weekly Checklist
pg. 4
Session 1: Handout
1. Remember, your health is a very important part of your recovery plan. The recovery process should
reflect all aspects of your life including your physical well-being. Continue with your mental health and
recovery plan.
2. Healthy food. When you are having a craving you may be hungry or thirsty.
Drink lots of water, reduce caffeine (coffee, tea, pop) and try to eat regularly throughout the day.
3. Daily activity. Start with 10 minutes, strive to get 30 minutes, this can improve your overall health and
reduce the risk of disease (you can break that up into 10 minutes, 3 times a day).
4. Find a balance between relaxation and stress. During times of stress, turn to support people and
activities that reduce your stress.
5. Make sure you have a primary care practitioner (family doctor, nurse, OT, psychiatrist or mental health
worker). Keep regular appointments to discuss your recovery plan. Schedule yearly vision and dental
exams and other screening tests as needed.
6. Take control of addictive behaviours. Part of the recovery process is attending to all issues that
impact our health and wellness and make a difference in the quality of our lives. Addressing addictive
behaviours including drinking alcohol and using other drugs including tobacco are important. Alcohol
and caffeine can be triggers for using tobacco.
Citation: Adapted from the Learning about Healthy Living Manual. Williams JM et. al. State of New Jersey, Division of Mental Health
Services. Revised June 2005.
Session 1
Handout
pg. 5
Session 1: Handout
Caffeine
• Caffeine occurs naturally in products such as coffee, tea, chocolate and cola type soft drinks and is
added to a variety of prescriptions and over the counter medications including cough, cold and
pain remedies.
• Energy drinks contain both naturally occurring and added caffeine.
• Caffeine is a stimulant that speeds up your central nervous system.
• The average amount of caffeine consumed per person in Canada is estimated to be approximately 2 cups
per day (210 – 238 mg).
How Does Caffeine Make You Feel?
• Caffeine stimulates the brain, elevates the mood and postpones fatigue.
• If you consume caffeine before bedtime, you will likely take longer to get to sleep, sleep for a shorter time
and sleep less deeply.
• Caffeine will not help you “sober up” if you’ve had too much alcohol. The caffeine will make you more alert
but your coordination and concentration will still be impaired.
• Too much caffeine can give you headaches, upset your stomach, cause restless leg syndrome, sweatiness,
make you nervous and jittery and leave you unable to sleep.
• It can also cause flushed face, increased urination, muscle twitching and agitation. Some people feel these
effects after as little as 2 cups a day.
• It takes about four hours for half of a given dose of caffeine to be metabolized by the body.
Is Caffeine Dangerous?
• Moderate amounts of caffeine – up to 400mg a day (3 average size cups 237 mg) will rarely harm an
otherwise healthy body.
• If you regularly drink more than 6-8 cups of coffee or your intake is higher than 600mg you may have
trouble sleeping and feel anxious and restless.
• Higher amounts can cause extreme agitation, tremors and very rapid irregular heartbeat.
• Combing high doses of caffeine with alcohol can be dangerous because caffeine can make you feel less
intoxicated, so you may continue to drink more or to behave in ways that are risky to you and others.
What Can You Do?
• Cut back on your caffeine consumption.
• Drink de-caffeinated or half caffeinated coffee.
• Switch to tea which has less caffeine.
Session 1
Handout
pg. 7
Caffeine
Session 1: Handout
There is no easy answer as to why so many people living with mental illness smoke. Smoking is a complex
problem made up of biological, psychological and social/environmental factors.
Biological Factors (Physical / Brain Functions)
People living with a mental illness may be at increased risk for physical addiction to smoking. Nicotine may
help improve mood, or mental functions like attention, memory or learning, in some people diagnosed with
mental illness.
Psychological Factors (Thinking / Feeling)
People may not feel confident that they can stop. People diagnosed with a mental illness may rely on smoking
to help them cope with stress.
Social Factors (People / Places / Things around You)
Smoking is common in and around mental health hospitals, treatment centres and group homes. People with a
mental illness may feel like it is easier to talk with others and be around others when they are smoking.
Session 1
Handout
pg. 6
Session 1: Handout
Key Questions
Why do you smoke?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What factors affect your smoking (addiction, thinking, feeling, places, things, people, etc.)?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 1
Handout
pg. 8
Key Questions
Session 1: Handout
3 Deep Breaths
Find a comfortable position either lying on your back or sitting. If you are sitting down, make sure that you
keep your back straight, feet flat on the floor and release the tension in your shoulders. Let them drop.
• Close your eyes.
• Place one hand on your stomach and the other on your chest.
• Take a few breaths as you normally would. Continue to take deep breaths.
• Concentrate on only moving your belly, filling it up like a balloon as you breathe out.
• Does your belly rise and fall with every in breath and out breath? If you can answer “yes”, that is good.
This is the natural way of breathing.
• If your belly stays still but your chest rises and falls with every breath, practice breathing by only allowing
your belly to rise and expand like a balloon as you take a breath in and then deflate and fall when you
breathe out.
• Continue as long as you like!
Tips:
It can take some time to re-learn how to breathe. The more you practice, the easier it becomes. Take some time
each day to practice this exercise. You can do it anywhere.
Try to practice this exercise at a time when you are already relaxed. This will make it easier to take deeper breaths.
If you are having trouble taking breaths, try breathing in through your nose and exhaling through your mouth.
Also, slowly count to five in your head as you breathe in and out.
Session 1
Handout
pg. 9
3 Deep Breaths
Session 1: Handout
Deep Breathing Exercise 2
• If you feel like yelling, slamming doors or ransacking the house for a cigarette, take a slow deep breath in
through your nose to the slow count of 5.
• Push your tummy out at the same time. This makes the air go deeply into your lungs.
• Slowly breathe out through your mouth to the count of 7.
• Repeat this 3 times as you feel yourself relaxing and the stress will start to drop away.
Session 1
Handout
pg. 10
Deep Breathing Exercise
2
Tab Session 2
Session 2:
Benefits
of Stopping
Feel.Awareness.Reward.Remind
Benefits of Stopping
Weekly Checklist – remind patients/clients to review and discuss any concerns.
CO Measurement (see Appendix B)
Group Guidelines – review flip chart
Group Member Check-in (10-15 minutes)
• How are patients/clients doing since the last session?
• Has anyone noticed any changes in the way they feel since the last session?
• Any questions or concerns?
• Has anyone thought of a name for the group?
Review homework from last week: “Key Questions” (Session 1: Handout).
“How Does Tobacco Advertising Affect Me?” (Session 2: Handout) Group discussion:
Option: show advertising from the past and discuss target audiences. Industry backgrounder and sample ads
can be found at this link: www.nsra-adnf.ca
• How do tobacco companies advertise in Canada? (Movies, TV, etc.)
• Who are the tobacco advertisements targeting?
• Will smoking make you a happier person? (If yes, for how long?)
• “What About Smoking ‘Light’, ‘Mild’, ‘Smooth’, ‘Gold’, or ‘Silver’ Cigarettes?” (see Appendix A:
Session 2: Resource)
“How Much Does Smoking Cost”: (Session 2: Handout) Group discussion
• How much money is a pack of 25 cigarettes? ($12 – $15)
• How much does a person spend on smoking daily, weekly, per month? (flip chart)
• What about time spent on smoking?
• How much money does the tobacco company spend per pack of cigarettes? (6 cents)
• How much money does the tobacco companies make each year? ($32 billion)
Homework: “Diary”, “Reward Yourself” and “What Are My Smoking Patterns?” (Session 2: Handout)
“3 Deep Breaths” (see Session 1: Handout)
Session 2
Benefits of Stopping
pg. 1
regular meals.
reading a book.
Session 2
Benefits of Stopping – Patient/Client Weekly Checklist
pg. 2
Session 2: Handout
How Does Tobacco Advertising Affect Me?
• The tobacco companies use a significant amount of money they make to pay for expensive advertising
in magazines.
• These ads focus on getting more people hooked on smoking every day.
The picture of the ad was taken at an unlicensed deli on Queen Street in Toronto.
The poster describes Macdonald Special as “A Canadian Tradition,” amid Canadian flag
imagery, associating this brand with a proudly patriotic way of life.
Citation: http://www.nsra-adnf.ca/cms/file/files/pdf/NSRA_Industry_Backgrounder_2012.pdf
Did you know that ½ of all cigarettes bought in the USA are purchased by people with mental health problems?
Did you know that the tobacco advertising agencies try to trick people into thinking that smoking is a lot of fun
or that it will make them a happier person? Sometimes ads even show people falling in love or making a lot of
friends. SMOKING CIGARETTES WILL NOT DO THAT!
Important Points to Remember
THE TOBACCO COMPANIES ARE TRYING TO TRICK YOU!
• Smoking WILL NOT make you a happier person.
• Smoking WILL NOT help you to make friends or fall in love.
• Light, extra light, ultra-light, silver, gold, special mild cigarettes give you the same dangerous chemicals as
regular brands. Every cigarette puts dangerous tar into the lungs of smokers.
Session 2
Handout
3
How Does Tobacco Advertising Affectpg.
Me?
Session 2: Handout
Cost of Cigarette = $0.50*
+ time spent (5 min / cig)
8 cigs / day
Daily
Weekly
Monthly
Yearly
$4.00
40 min
$120.00
20 hours
$1,440.00
10 days
½ pack (13 cigs) day
$6.50
1 hour
5 min
$28.00
4 hours
20 min
$45.50
7 hours
35 min
$2,340.00
16 days
6 hours
1 pack
$12.50
2 hours
5 min
$87.50
14 hours
35 min
2 packs
$25.00
4 hours
10 min
$175.00
1 day
5 hours
10 min
$195.00
1 day
8 hours
30 min
$375.00
2 days
14 hours
30 min
$750.00
5 days
5 hours
$4,500.00
31 days
15 min
$9,000.00
2 months
2 days
30 min
*2013 price estimates
Session 2
Handout
pg. 4
Session 2: Handout
Diary
Cigarette #
Time of Day
Need*
What I
Was Doing
Who I
Was With
Reason for
Cigarette
*Rate your personal need for a cigarette at this time
(1 = low, 10 = high)
Session 2
Handout
pg. 6
Diary
Session 2: Handout
Reward Yourself
List ways you can reward yourself/others for stopping smoking:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 2
Handout
pg. 5
Reward Yourself
Session 2: Handout
Smoking patterns are the usual times, situations, actions and things that make you feel like you want to have a
cigarette. For example, if whenever you sit to have a cup of coffee you light up a cigarette, this is a smoking pattern.
Identifying your smoking patterns is being able to recognize “when” and “why” you smoke on a typical day.
Understanding “when” and “why” you smoke is an important first step in helping you later when you decide
that you are ready to stop.
Common Smoking Patterns
Check () all of the patterns that apply to you or use as a group brainstorming session and flip chart responses.
___ Getting out of bed
___ Driving, or sitting in the car
___ Talking on the phone
___ Drinking coffee
___ Sitting at the table
___ Going to your program or work
___ Waiting at a bus stop, train station, subway or airport
___ Taking a break at your program or work
___ Watching TV
___ After an argument
___ After a treatment group or session
___ After lunch
___ After dinner
___ Dealing with a stressful situation at home
___ Other _______________________________________________
Session 2
Handout
pg. 7
Tab Session 3
Smoking
Placeholder page, not for
print
Session 3:
and Your Body
Practice.Improve.Strength.Grow
Smoking and Your Body
Weekly Checklist – remind patients/clients to review and discuss concerns
Icebreaker: If you could have super powers, what super powers would you have? Would you be the hero or
the villain?
Review homework from last week: “Diary”, “Reward Yourself” and “What Are My Smoking Patterns?”
(Session 2: Handout)
“Nicotine Addiction” (Session 3: Handout)
“Why is Smoking Dangerous?” (Session 3: Handout) Group discussion (flip chart responses)
“Chemicals Found in Cigarettes” (Session 3: Handout) Group discussion and flip chart:
Flip chart the following question: What do nail polish remover, ant poison, lighter fluid, toilet bowl cleaner and
moth balls have in common? Answer: they all contain poisons/chemicals that are found in cigarettes.
• If there are any questions about illegal/contraband cigarettes see, “Contraband, the Facts”
(see Appendix A: Session 3: Resource).
• Go over some of the chemicals found in cigarettes and discuss other products where these chemicals are found.
• Remind patients/clients that nicotine is an addictive substance, and cigarettes rapidly introduce nicotine
and 7,000 other chemicals to the body.
Session 3
pg. 1
“Changes Your Body Goes Through When You Stop Smoking!” (Session 3: Handout) Group discussion
• Did anyone experience any of these changes when they stopped smoking in the past?
• What changes are patients/clients looking forward to?
“Stop Smoking, Save Your Smile” (Session 3: Handout)
• Homework: “Your Personal Benefits of Stopping Smoking” (Session 3: Handout) I want to stop
smoking because…
• List your own personal benefits to stopping smoking.
Session 3
pg. 2
regular meals.
reading a book.
Session 3
Smoking and Your Body – Patient/Client Weekly Checklist
pg. 3
Session 3: Handout
Nicotine Addiction
Nicotine is a chemical compound found in tobacco.
Nicotine causes and keeps people addicted to tobacco.
Within seconds of inhaling, nicotine reaches the brain.
Over time the brain adjusts to the nicotine and you may need to smoke more to get the same feeling (which
has been described as a “high”) or effect of smoking.
Eventually your brain will adjust and no longer produces the same feeling, it produces a feeling that you think
of as normal.
The power of nicotine comes from the repeated small doses you give yourself when you smoke. If you smoke
12 puffs from a cigarette and smoke 20 cigarettes a day, that’s 240 drug doses a day or 87,600 doses a year.
When you stop or reduce your smoking, you won’t feel the same. Your brain and body need a few days or
weeks to adjust. The adjustment is known as withdrawal.
Each person reacts differently to nicotine and some develop a more powerful physical addiction than others.
So, some may experience a more intense physical withdrawal that could last longer than average.
Some people experience many withdrawal symptoms, while others experience few.
Session 3
Handout
pg. 9
Nicotine Addiction
Session 3: Handout
Here are some facts to consider about tobacco and smoking.
• For every 5 deaths per year in this country, at least 1 is due to smoking.
• Smoking causes 9 out of 10 (90%) cases of lung cancer.
• Smoking causes nearly all cases of chronic obstructive pulmonary disease (COPD, chronic asthma/
bronchitis or emphysema).
• People who smoke are twice as likely to die from stroke or heart attack, compared to non-smokers.
• People who smoke miss more days of work than non-smokers.
• Smoking is also a risk factor for cancer of the mouth, throat, stomach, pancreas, kidney, bladder, cervix,
liver, esophagus, uterus, colon, and leukemia.
Session 3
Handout
pg. 4
Session 3: Handout
When you smoke you inhale up to 7000 chemicals including these poisons that are found in the
following products:
Acetone: Paint Stripper and Nail Polish Remover
Ammonia: Floor Cleaner
Arsenic: Ant Poison
Benzene*: Industrial Solvent/Fuel, Dyes, Synthetic Rubbers
Butane: Lighter Fluid, Key Component of Gasoline
Cadmium*: Used in Car Batteries
Carbon Monoxide: Poisonous Gas in Car Exhaust
DDT: Insecticides
Formaldehyde*: Embalmers use to Preserve Dead Bodies
Hydrogen Cyanide: Poison used in Gas Chambers
Methanol: Rocket Fuel
Phenol: Disinfectants
Naphthalene: Mothballs
Toluene: Industrial Solvent
*Other known cancer causing substances:
Naphthylamine, Pyrene, Benzopyrene, Vinyl Chloride,
Toluidine, Urethane, Dibenzacridine, Polonium-210.
Services. Revised June 2005. Please note: Dr. Charl Els, personal communication, Jan 2013.
Session 3
Handout
pg. 5
Session 3: Handout
1 – 9 Months
20 Minutes
Cilia in lungs re-grow and help
clean lungs – shortness of breath
and coughing decreases.
Blood pressure and pulse
lowered – skin temperature
returns to normal.
2 – 12 Weeks
8 – 24 Hours
Lungs work better,
blood flow improves –
walking and exercise
becomes easier.
Oxygen to body parts
increases – carbon
monoxide levels decrease
– lowered chance of heart
attack already!
48 – 72 Hours
Taste and smell improves
– nerves begin to re-grow –
bronchial tubes relax –
lung space increases.
And the BEST is yet to come…
Session 3
Handout
pg. 6
Session 3: Handout
Changes Your Body Goes Through When You Stop Smoking! (con’t)
It’s Worth It!
More Energy!
10 Years
1 Year
Lowered risk of
many cancers
(mouth, throat, kidney)
Greatly lowered risk of
heart attack.
Feel Better
Session 3
Handout
pg. 7
Session 3: Handout
Save Your Smile…
STOP SMOKING
Your smile is one of the first things people see. Let’s protect it.
There are many dental/oral health benefits to reducing or stopping the use of tobacco products.
•
•
•
Better breath
Improved taste and smell
Less staining of teeth and fillings
•
•
•
Reversal of smoker’s palate (the palate turns
white with many raised lumps with white centers)
Less gum disease
Less tartar forming on teeth
Use the Four D’s (Delay, Drink Water, Do Something Different, Deep Breathe)
to cope with nicotine cravings:
DELAY
Get in the flossing habit – try flossing
at a time when you would have reached
for a cigarette. Many new products
have floss on a handle or are battery
powered to make flossing easier.
DO SOMETHING DIFFERENT
If after a meal you used to reach for a
cigarette, try chewing sugarless gum instead.
Chewing sugarless gum has been shown to
increase saliva and saliva helps prevent tooth
decay. Smoking dries up the saliva and
promotes tooth decay.
Brush your teeth. Have that old familiar
urge to pick up a cigarette? Pick up a
toothbrush and toothpaste instead
and enjoy the nice clean feeling left in
your mouth after brushing.
DRINK WATER
Between meals, water is the best choice for
your dental health.
Coffee and tea stain teeth. Many soft drinks and juices
not only contain sugar but are very acidic, which can
lead to tooth decay.
Another alternative might be having raw
vegetables such as carrots, celery, cucumber
or broccoli ready to munch. These are low in
calories and do not cause tooth decay.
DEEP BREATHE
Deep breathing is a great way to cope with the tension
caused by reducing or stopping tobacco use. It can be
done at any time of day, whether you are sitting, standing,
lying down, driving, sitting at a meeting or waiting for
someone. Practice deep breathing at least twice a day,
every day or whenever you are bothered by tension.
REWARD YOURSELF FOR NOT SMOKING
Have your teeth professionally cleaned by your dental hygienist or dentist. Admire your smile free of tobacco stains.
Be sure to tell your dental professional that you are quitting tobacco. They too can offer some helpful tips on quitting.
Don’t let a slip discourage you? No one is perfect!
You are worth the effort!
Canadian Cancer Society
Smoker’s Helpline
www.smokershelpline.ca
Hours:
Phone Toll Free and Confidential
1-877-513-5333
Mondays – Thursdays 9am – 10pm
Fridays 9am – 7pm
Saturday – Sunday 10am – 6pm
Session 3
Handout
pg. 10
Session 3: Handout
CHEWING TOBACCO
Chewing tobacco contains: nicotine, embalming fluid,
pesticides, flavoring agents, cancer causing chemicals,
radioactive compounds and over 30 metals. The use of
chewing tobacco or snuff can lead to nicotine addiction and
is not a safe alternative to cigarettes. The risk of oral cancer is
higher in smokeless tobacco users than cigarette smokers.
Chewing tobacco is as addictive as a cigarette.
Tobacco products such as chewing tobacco and snuff have
similar serious oral effects as cigarette smoking:
•
•
•
•
•
•
•
Stained teeth
Bad breath
Gum irritation
Gum recession
Enamel wear due to grit and
sand in smokeless tobacco
Increased tooth sensitivity
Increased tooth decay
ORAL CANCER
Look for early warning signs of oral cancer.
Some signs may be:
•
•
•
•
•
•
Any sores on the face, neck or mouth
that do not heal within two weeks.
Swellings, lumps, or bumps on the lips,
gum, jaw, inside the mouth or throat.
White, red, or dark patches in the mouth.
Unusual bleeding, pain or numbness.
A change in one’s voice.
Pain in the ear.
If you have symptoms or signs always see a dentist or doctor:
EARLY DETECTION IS THE KEY
TO SUCCESSFUL TREATMENT!
Contact your Public Health Dental Hygienist
for more information
THE TOBACCO INDUSTRY’S CLEVER ADVERTISING
OF FLAVORED CHEWING TOBACCO IS MISLEADING,
BE AWARE!
USEFUL RESOURCES
http://www.umanitoba.ca/outreach/wisdomtooth/smoking.htm
http://www.cdha.ca/content/oralcare_centre/facts_smoking.asp
Health Canada – www.gosmokefree.ca
www.gov.ns.ca/http/www.sickofsmoke.com
NS Health Promotion & Protection, Tobacco Control
Smokers’ Helpline – 1-877-513-5333
Hours:
Fridays 9am – 7pm
Produced by Public Health Services.
May be reproduced provided source is acknowledged.
Session 3
Handout
pg. 11
Session 3: Handout
I want to stop smoking because:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
List your own personal benefits of stopping smoking:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 3
Handout
pg. 8
Tab Session 4
Session 4:
Replacement
Placeholder Nicotine
page, not for print
Therapy
& Pharmacotherapy
D i s c u s s . S t r a t e g i e s . R e v i e w . B e n e fi t
Nicotine Replacement Therapy & Pharmacotherapy
Weekly Checklist – remind patients/clients to review and discuss any concerns
Review homework from last week: “Your Personal Benefits of Stopping Smoking” (Session 3: Handout).
Ask patients/clients if they would like to share their responses.
“Life Without Nicotine” (Session 4: Handout) Group discussion
“Nicotine” (Session 4: Handout)
“Nicotine Replacement Therapy and Pharmacotherapy”, “Patch, Nicotine Gum, Lozenge, Inhaler,
Mouth Spray, Varenicline, Bupropion” (Session 4: Handout), “Algorithm for Tailoring Pharmacotherapy
in Primary Care Settings” (see Appendix A: Session 4: Resource)
“Better Coping Strategies” (see Appendix A: Session 4: Handout) Group discussion
• What skills/strategies are you using or could use to help with the cravings? (Flip chart )
“What Happens When I Stop Smoking” (Session 4: Handout) Group discussion
Has anyone tried to stop smoking in the past without using pharmacotherapy or a nicotine replacement
product i.e. reduce and stop or “Cold Turkey”?
• What was it like to reduce or stop in the past? How do you think it will be different now?
“E-Cigarettes” (see Appendix A: Session 4: Resource)
Session 4
pg. 1
“What Can Help Me Stop Smoking?” (Session 4: Handout) Group discussion
• What products are available?
• Discussion about pharmacotherapy and nicotine replacement products.
Homework: “My Questions About Nicotine Replacement Therapy and Pharmacotherapy”
(Session 4: Handout)
“Better Coping Strategies” (Session 4: Handout). Review and select (circle) the ones that apply to you.
Session 4
pg. 2
regular meals.
reading a book.
Session 4
Nicotine Replacement Therapy & Pharmacotherapy – Patient/Client Weekly Checklist
pg. 3
Session 4: Handout
Everyone’s experience is different, but here are a few common withdrawal symptoms:
• Irritability, frustration, anger or anxiety
• Difficulty in concentrating
• Restlessness
• Problems falling asleep or frequent waking
• Slight depression or feeling down
Dealing with withdrawal may not be easy, but you should know that:
• Most nicotine from your smoking is flushed from your body after an average of 4 to 5 days.
• The withdrawal symptoms start during the first day and peak on the second or third day.
They usually subside the fourth week.
• For those who suffer from intense withdrawal symptoms, there are many simple medical treatments to
help. The nicotine patch and other medications may be helpful. The key is to use them properly, and in
combination with programs.
The symptoms you may experience in the first few days happen because your body is returning to normal.
Urges to smoke may also be related to the fact that your behavioural and social routines have changed.
Keep in mind that cravings will last for only a few minutes.
Remember, you are important and deserve a healthy and smoke-free life. Be an individual. You don’t have to
be like your friends and relatives in every way. You don’t need to be pencil-thin to be attractive. You can cope
with stress and anger in many different ways.
Citation: One Step at a Time for smokers who want to quit. Canadian Cancer Society www.cancer.ca
Citation: http://www.drugabuse.gov/publications/research-reports/tobacco-addiction/nicotine-addictive
Citation: http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/tobacco/Pages/about_
tobacco.aspx
Session 4
Handout
pg. 4
Session 4: Handout
Nicotine
Nicotine addiction involves psychological and physical factors. Psychological factors may include feelings of
pleasure and alertness. People who smoke regularly may learn to rely on the effects of nicotine to bring about
these feelings.
Nicotine in tobacco smoke travels quickly to the brain, where it acts as a stimulant and increases heart rate
and breathing.
Tobacco smoke reduces the level of oxygen in the bloodstream, causing a drop in skin temperature.
Smoking raises levels of dopamine, a chemical in the brain, increasing feelings of pleasure and reinforcing the
desire to continue to smoke.
Tobacco smoke may cause headaches, dizziness, nausea, coughing and wheezing, and can aggravate allergies
and asthma.
Smoking also weakens the sense of taste and smell, reduces hunger and causes the stomach to produce acid.
Burning tobacco forms carbon monoxide (CO), a poisonous gas you can’t see or smell. When smoke is inhaled,
CO replaces oxygen in red blood cells.
While nicotine speeds up the heart, making it work harder, CO deprives it of the extra oxygen this work
demands. This is one way that smoking contributes to heart disease.
When swallowed, nicotine is extremely toxic. Ingesting about 40 milligrams of pure nicotine, or roughly the
amount contained in two cigarettes, is fatal.
*** However, when a cigarette is smoked, most of the nicotine is burned, and only one to four milligrams is
absorbed into the body.
*** Similarly, the amount of nicotine absorbed from the patch, and other methods of nicotine replacement
therapy used to help people quit smoking, is well below toxic levels.
*** Nicotine is not known to lead to any diseases. It is the 7000+ chemicals in cigarette smoke that contribute
to the diseases. The other chemicals involved in burning tobacco (tar) and the paper found in a cigarette that
responsible for diseases and death.
Citation: http://www.camh.ca
Personal Communication, Dr. Charl Els; Jan 2013
Session 4
Handout
pg. 5
Nicotine
Session 4: Handout
Nicotine Patch
How would I benefit from using this medication?
Nicotine patches slowly deliver nicotine through the skin and into the blood. Nicotine patches can help
individuals reduce or quit smoking by gradual weaning off nicotine. Nicotine patches help to reduce the
symptoms of nicotine withdrawal and control cravings for nicotine. Those who use nicotine patches when
attempting to quit smoking are roughly twice as likely to be successful as those who do not.
How should I use this medication?
A target quit date is set and then the nicotine patch is started on that day. Some people may benefit using
the patch before the quit date. The nicotine patch is available over the counter. There are different strengths
and brands of nicotine patches available. Nicotine patches are generally applied in the morning to a clean,
dry, hairless application site on the upper arm, hip, back, or shoulder. Some brands of nicotine patches are left
on for 24 hours, then removed and replaced with a new patch. Other brands are designed to deliver nicotine
over a 16-hour period and are removed at bedtime to allow for a nicotine-free period. Consultation with a
healthcare provider can help to determine the appropriate starting strength of nicotine patch and schedule for
reducing the strength of patch.
What are the common side effects with this medication?
The most common side effects of nicotine patches include itching or burning at the site of application.
This usually goes away in about an hour following application but can persist if an individual is allergic to
the patch components. Applying the patch to a new site and avoiding using the same site within 1 week can
reduce the risk of skin irritation. Sometimes switching to a different brand of patch may reduce skin irritation in
those with persistent skin reactions. For those who experience difficulty sleeping while using nicotine patches,
removing the patch 1-2 hours prior to bedtime may help.
What symptoms would indicate that I should stop taking this medication?
If you experience chest pain, irregular heartbeat, leg pain, fainting, or severe stomach upset, consider stopping
the patch and contacting your healthcare provider.
Can I use other forms of nicotine replacement therapy while using nicotine patches?
Yes, nicotine patches can be used with other forms of nicotine replacement therapy for those individuals who
do not have adequate craving control when using nicotine patches. Nicotine gum, for example, can be used
with the patch on an as needed basis when cravings occur and may provide faster relief of cravings than the
patch, which can take up to 2-4 hours.
Session 4
Handout
11
Nicotinepg.
Patch
Session 4: Handout
Nicotine Patch (con’t)
What can happen if I consume caffeine while taking this medication?
It is generally advised to reduce caffeine (e.g. in tea, coffee, colas, energy drinks, etc.) intake when quitting
smoking because the tar in cigarette smoke helps the liver to process caffeine more quickly. When you stop
smoking, the liver’s ability to process caffeine returns to its normal level, and the effect of caffeine will feel
stronger and may produce symptoms similar to nicotine withdrawal (for example, irritability and anxiety).
Reducing caffeine consumption prior to quitting can help to avoid unpleasant effects of excessive caffeine.
How will nicotine patch affect other medications?
Nicotine replacement therapy does not directly affect blood levels of other medications. However, quitting
smoking does affect the blood levels of some medications. The potential need for dose adjustments of other
medications should be discussed with a healthcare provider.
Citation: Pohar, R (in Els, Kunyk, & Selby, Disease Interrupted; 2012. URL: www.diseaseinterrupted.com)
Session 4
Handout
12
Nicotinepg.
Patch
Session 4: Handout
Nicotine Gum
What are the benefits of this medication?
Nicotine gum can help individuals to reduce or quit smoking by gradually weaning off nicotine. Nicotine gum
helps to reduce the symptoms of nicotine withdrawal (irritability, frustration, anxiety, restlessness, difficulty
concentrating) and to control cravings for nicotine. Those who use nicotine gum when attempting to quit are
about twice as likely to be successful as those who do not.
How should this medication be used?
When you are ready to stop smoking, set a target quit date. On that day, nicotine gum can be started.
In general, most people will start with 10-20 pieces per day (1-2 pieces every 1-2 hours) and then slowly reduce
the number of pieces chewed each day. The nicotine gum is available over the counter. Consultation with a
healthcare provider can help to determine the appropriate strength of nicotine gum (2 mg or 4 mg based
on the number of cigarettes smoked per day and the time to first cigarette) and schedule for reducing the
number of pieces of gum chewed each day. For those individuals not yet prepared to quit smoking altogether,
a “reduce-to-quit” approach can be used whereby the number of cigarettes smoked daily is gradually reduced.
Nicotine gum is not like ordinary chewing gum and must be chewed a specific way in order for it to be
maximally effective and to reduce the chance of having side effects. Use the “bite-and-park” technique:
the gum should be bitten (chewed) once or twice and then “parked” between the cheek and gum for about
1 minute. The gum is then repeatedly chewed then parked for about 30 minutes, after which time all of the
nicotine will have been released. Eating or drinking 30 minutes before use or during use or the consumption of
caffeinated or acidic beverages while chewing nicotine gum should be avoided.
The most common side effects of nicotine gum include feeling light-headed, nauseous, and having hiccups.
Often these side effects are related to incorrect chewing technique and will subside if the chewing technique
is corrected.
use of the gum and contact your healthcare provider.
What can happen if I smoke while taking this medication?
Smoking while using nicotine gum is part of the reduce-to-quit strategy and may help those who have
previously been unable to quit to do so.
Session 4
Handout
9
Nicotine pg.
Gum
Session 4: Handout
Nicotine Gum (con’t)
Can I use other forms of nicotine replacement therapy while using nicotine gum?
Yes, nicotine gum can be used in combination with nicotine patches on an as-needed basis when cravings
occur and may provide faster relief of cravings than the patch, which can take up to 2 – 4 hours.
smoking, the liver’s ability to process caffeine returns to its normal level and the effect of caffeine will feel
How will nicotine gum affect other medications?
Nicotine gum does not directly affect blood levels of other medications. However, quitting smoking does affect
the blood levels of some medications. The potential need for dose adjustments of other medication should be
discussed with a healthcare provider.
Session 4
Handout
10
Nicotinepg.
Gum
Session 4: Handout
Nicotine Lozenge
Nicotine lozenges can help individuals to reduce or quit smoking by gradually weaning off nicotine.
Nicotine lozenges help to reduce the symptoms of nicotine withdrawal (irritability, frustration, anxiety,
restlessness, difficulty concentrating) and to quickly control cravings for nicotine. Those who use nicotine
lozenges when attempting to quit are about twice as likely to be successful as those who do not.
Set a target quit date for stopping smoking and start using nicotine lozenges that day. Nicotine lozenges are
available over the counter. Nicotine lozenges are placed in the mouth and left to dissolve, delivering nicotine
through the lining of the mouth while the lozenge dissolves. The lozenge is occasionally moved from one side
of the mouth to the other until it dissolves completely, which takes about 20 to 30 minutes. Lozenge tablets
should not be chewed or swallowed as this will reduce absorption of nicotine. Avoid eating or drinking
15 minutes before and during use of nicotine lozenges. Nicotine lozenges are available in two strengths
(2mg and 4mg). Consultation with a healthcare provider can help you determine which strength is appropriate
based upon the number of cigarettes smoked each day and how soon after awakening the first cigarette is
smoked. Generally, 1 to 2 lozenges are used every 1 to 2 hours to a maximum of 15 lozenges per day.
Smoking cessation is most successful when at least 8 lozenges are used daily. Nicotine lozenges are continued
for up to 6 months, during which time the dose is reduced. During the tapering period, it might be helpful to
substitute sugarless candy for the lozenges.
A hot or tingling sensation usually occurs as the lozenge dissolves. Mouth or throat irritation can occur, as can
nausea, heartburn, headaches, and hiccups. Side effects are more common when lozenges are taken one after
the other and tend to subside with continued use of the nicotine lozenge.
use of the lozenge and contacting your healthcare provider.
Can I drink beverages with caffeine while taking this medication?
How will nicotine lozenges affect other medications?
Nicotine lozenges do not directly affect blood levels of other medications. However, quitting smoking does
affect the blood levels of some medications. The potential need for dose adjustments of other medications
should be discussed with a healthcare provider.
Session 4
Handout
pg. 19
Nicotine Lozenge
Session 4: Handout
Nicotine Inhaler
The nicotine inhaler can help individuals to reduce or quit smoking by gradually weaning off nicotine.
The nicotine inhaler helps to reduce the symptoms of nicotine withdrawal (irritability, frustration, anxiety,
restlessness, difficulty concentrating) and to control cravings for nicotine. The nicotine inhaler is also helpful
because it can serve as a substitute for the hand-to-mouth ritual that is part of cigarette smoking. Those who
use nicotine inhalers when attempting to quit are about twice as likely to be successful as those who do not.
How should I use medication?
Set a target quit date for stopping smoking. On that day, use of the nicotine inhaler can be started. The nicotine
inhaler is available over the counter. The nicotine inhaler requires assembly of a mouthpiece and cartridge.
After assembling the inhaler and cartridge, the mouthpiece is placed in the mouth and the user inhales deeply
into the back of the throat or puffs in short breaths. This allowed the nicotine to be absorbed through the
lining of the mouth and throat and into the bloodstream. Nicotine from the inhaler is absorbed into the body
more slowly than nicotine from a cigarette, which is absorbed from the lungs. Because of this, it takes about
3-4 times longer to notice an effect with the nicotine inhaler than with a cigarette. Each cartridge is designed
to provide 80 inhalations over a 20-minutes period but the entire cartridge does not have to be used at one
time. For example, if you use the inhaler for 5 minutes at a time, the cartridge can last for 4 uses. Generally, 6-12
cartridges are used each day for 3 months, and then the number of cartridges is gradually reduced over a 6-12
week period. The inhaler should be kept between 15 degrees C to 30 degrees C, so avoid storing them in a car
during extreme temperatures.
The most common side effects of the nicotine inhaler include a mild irritation in the mouth and/or throat
and cough. Stomach upset can also occur. With continued use of the nicotine inhaler, these side effects tend
to subside.
If you experience chest pain, irregular heartbeat, leg pain, fainting or severe stomach upset, consider stopping
the use of the inhaler and contacting your healthcare provider.
Session 4
Handout
pg. 17
Nicotine Inhaler
Session 4: Handout
Nicotine Inhaler (con’t)
It is generally advised to reduce caffeine (e.g. in tea, coffee, colas, energy drinks, etc) intake when quitting
Also, coffee, tea, citrus juice, soft drinks, and alcohol are best avoided 30 minutes before and after using the
nicotine inhaler because these may prevent the medication from working properly.
How will the nicotine inhaler affect other medications?
Generally, the nicotine inhaler does not directly affect blood levels of other medications. However, quitting
medications should be discussed with a healthcare provider.
Session 4
Handout
pg. 18
Nicotine Inhaler
Session 4: Handout
Nicotine Mouth Spray
Nicotine mouth spray can help individuals to reduce or quit smoking by gradually weaning off nicotine.
The spray helps to reduce the symptoms of nicotine withdrawal (irritability, frustration, anxiety, restlessness,
difficulty concentrating) and to control cravings for nicotine. Those who use nicotine mouth spray when
attempting to quit are about twice as likely to be successful as those who do not.
Set a target quit date for stopping smoking. On that day, the nicotine mouth spray can be started. The nicotine
mouth spray is available over the counter. During the first 6 weeks, use 1 or 2 sprays when you would usually
smoke and when craving cigarettes. Generally 1-2 sprays are used every 30-60 minutes. The maximum dose
of nicotine mouth spray is 2 sprays at 1 time, 4 sprays in 1 hour, and 64 sprays in 24 hours. During weeks 7-9,
reduce the number of sprays that you use each day, with the goal of reaching half the amount originally used
by the end of week 9. By week 12, you should be using about 2-4 sprays each day. Nicotine mouth spray is
generally used for 3-6 months.
Nicotine mouth spray must be unlocked prior to use according to the package insert. Before using nicotine
mouth spray for the first time, the pump must be loaded (primed) by spraying it into the air a few times until
a fine spray comes out. To administer the spray, hold it as close to your open mouth as possible and press
the top of the device to activate one spray. Avoid inhaling during spraying and avoid contact with the lips.
Do not swallow for a few seconds following administration. A second spray can be used if needed. It is then
recommended to close the spray pump (according to directions found in the package insert) to avoid
accidental administration. The pump must be primed again prior to administration if it has not been used
for more than 2 days.
The most common side effects of nicotine mouth spray include hiccups, headache, nausea, tingling, or burning
in the mouth, dry mouth, increased production of saliva, and stomach upset.
the use of the nicotine mouth spray and contacting your healthcare provider.
Session 4
Handout
20
Nicotine Mouthpg.
Spray
Session 4: Handout
Nicotine Mouth Spray (con’t)
smoking, the liver’s ability to process caffeine returns to its normal level and the effect of caffeine will feel
Also, coffee, tea, citrus juice, soft drinks, and alcohol are best avoided 15 minutes before and after using
nicotine mouth spray because they may prevent the medication from working properly.
How will nicotine mouth spray affect other medications?
Generally, nicotine mouth spray does not directly affect blood levels of other medications. However, quitting
medications should be discussed with a healthcare provider. Nicotine mouth spray contains a small amount
of alcohol (ethanol). Sixty-four doses per day of the mouth spray would contain about the same amount of
alcohol as one teaspoonful of wine containing 12% ethanol.
Session 4
Handout
21
Nicotine Mouthpg.
Spray
Session 4: Handout
Varenicline
When used with supportive counselling, individuals who take varenicline are 2-3 times more likely to quit
smoking than those who do not. Varenicline helps to reduce symptoms of nicotine withdrawal and craving of
cigarettes by affecting receptors in the brain that are involved with nicotine addiction. Varenicline does not
contain nicotine.
How should I take this medication?
A date to stop smoking is set prior to starting treatment with varenicline and should ideally be between
8 and 14 days after you start taking varenicline. Varenicline is only available by prescription. Treatment with
varenicline is started with 0.5 mg daily on days 1-3, then increase to 0.5 mg twice daily for days 4-7 (one tablet
with breakfast and one tablet with supper). After the first week of treatment, the dose of varenicline may
remain at 0.5 mg twice daily or may increase to 1.0 mg twice daily (i.e. a total daily dose of 2 mg) depending
on side effects and how well varenicline is working. Varenicline is continued for 12 weeks and possibly longer
for those who have stopped smoking or substantially reduced their cigarette consumption during the first
12 weeks of treatment. Varenicline can also be used effectively at a total dose of 1.0 mg per day (i.e. 0.5 mg
twice a day).
The most common side effects of varenicline include those that affect the stomach (e.g. nausea and vomiting).
As well, some individuals experience difficulty sleeping and vivid or unusual dreams. These side effects generally
occur in the first weeks of treatment and may go away with continued use. Some individuals (those with and
without previous issues with their mental health) have experienced changes in behaviour or mood while taking
varenicline. However, similar mood and behaviour changes can occur due to nicotine withdrawal and when
quitting smoking without taking varenicline.
Changes in behaviour may suggest that treatment with varenicline be re-evaluated. Examples of behavioural
changes that require further follow-up may include increased agitation, restlessness, anxiety, or aggression;
development of hallucinations; ability to control impulses; and feeling hostile, symptoms of mania, feeling
depressed, confused, paranoid, or suicidal. If you experience these feelings or any others that are concerning,
consider stopping the use of varenicline and contacting a healthcare provider.
Prior to the target quit date, you may continue to smoke while taking varenicline but may notice that
varenicline may change the taste of cigarettes. Smoking after the target quit date, however, reduces the
chances of successfully quitting.
Session 4
Handout
pg. 13
Varenicline
Session 4: Handout
Varenicline (con’t)
What can happen if I drink alcohol while taking this medication?
Drinking alcohol may increase the chances of experiencing changes in behaviour when taking varenicline.
It is generally advised to reduce caffeine intake when quitting smoking because the tar in cigarette smoke
helps the liver to process caffeine more quickly. When you stop smoking, the liver’s ability to process caffeine
returns to its normal level, and the effect of caffeine will feel stronger and may produce symptoms similar to
nicotine withdrawal (for example, irritability and anxiety). Reducing caffeine consumption prior to quitting can
help to avoid unpleasant effects of excessive caffeine.
How will varenicline affect my other medications?
No important drug interactions with varenicline have been identified to date but quitting smoking can affect
the blood levels of some medications. The effect of quitting smoking on your other medications should be
discussed with a healthcare provider.
Session 4
Handout
pg. 14
Varenicline
Session 4: Handout
When used with supportive counselling, individuals who take bupropion are about twice as likely to quit
smoking as those who do not. Bupropion helps to reduce symptoms of nicotine withdrawal and cravings of
cigarettes but does not contain nicotine and is not related to nicotine.
How should I take this medication?
A date to stop smoking is set prior to starting treatment with bupropion. This date should be roughly during
the second week of treatment because bupropion takes about 1 week to start working. Bupropion is only
available by prescription. For the first 3 days of treatment, 150 mg of bupropion is taken in the morning.
The dose is then increased to 150 mg twice daily with 1 tablet taken in the morning and the other in early
evening at least 8 hours after the first tablet. Treatment with bupropion is generally continued for 12 weeks
but may be taken longer if needed.
The most common side effects of bupropion include dry mouth and insomnia (difficulty sleeping).
These side effects are most common in the first weeks of treatment and may go away with continued use.
Sucking on sugarless candy or chewing sugarless gum can help with dry mouth. Taking the second dose of
bupropion in the early evening (e.g. 6:00 pm) may help with insomnia. Less common side effects include
hallucinations and behavioural changes such as increased impulsiveness, agitation, anxiety, aggression or
hostility and feeling suicidal or thinking of harming yourself or others. If you experience these feelings or any
others that are concerning to you, consider stopping bupropion and contacting a healthcare provider. Similar
mood and behaviour changes can, in fact, occur due to nicotine withdrawal and when quitting smoking
without taking bupropion.
What is the risk of seizures when taking this medication?
There is a risk of seizure (approximately 0.1%) when taking bupropion. Certain medical conditions (e.g. a
seizure disorder, eating disorder, history of liver problems, or head injury) and medications can increase the
risk of seizures. Taking more than the recommended dose of bupropion also increases the risk of seizures.
Do not take more than 150 mg twice daily of bupropion and if a tablet is missed, just take bupropion at the
next scheduled dosing time. Do not double the doses of bupropion, as this may theoretically increase the
seizure risk.
Changes in behaviour may suggest that bupropion should be discontinued. A healthcare provider should be
contacted if behavioural changes occur.
Session 4
Handout
pg. 15
Session 4: Handout
Sustained-Release (SR) Bupropion (con’t)
Prior to the target quit date, you will continue to smoke while taking bupropion; however, smoking after the
target quit date may reduce the chances of successfully quitting.
Can I use nicotine replacement therapy while taking this medication?
Yes, bupropion can be used in combination with nicotine patches and other forms of nicotine replacement
therapy (such as gum).
What can happen if I drink alcohol while taking this medication?
Drinking alcohol while taking bupropion is not recommended as it may increase the changes of having a
seizure or allergic reaction. As well, bupropion may make you more sensitive to the effects of alcohol.
It is generally advised to reduce caffeine intake when quitting smoking because the tar in cigarette smoke
helps the liver to process caffeine more quickly. When you stop smoking, the liver’s ability to process caffeine
returns to its normal level, and the effect of caffeine will feel stronger and may produce symptoms similar to
nicotine withdrawal (for example, irritability and anxiety). Reducing caffeine consumption prior to quitting can
help to avoid unpleasant effects of excessive caffeine.
How will bupropion affect other medications?
Bupropion can interact with a number of medications and quitting smoking can also affect the blood levels of
some medications. The potential need for dose adjustments of other medications should be discussed with a
healthcare provider.
Session 4
Handout
pg. 16
Session 4: Handout
Things you can do instead of smoking!
1.
Take a long walk
2.
Put together a list of household jobs to keep your hands busy
3.
Take a hot bath or shower
4.
Smile a lot
5.
Keep your hands busy by squeezing a stress ball or playing with “silly putty”
6.
Keep a sense of humour
7.
Sing with a group or by yourself
8.
Read a book
9.
Jog or speed walk
10. Do needlework
11. Walk or window shop at the mall
12. Get outside for some fresh air
13. Learn to accept things you cannot change
14. Help someone else
15. Write a letter to a friend
16. Go to a movie
17. Practice deep breathing
18. Pray or go to church
19. Talk to a friend
20. Listen to music that you like and helps you to relax or energizes you
21. Take a short nap
22. Think positive thoughts about yourself. Recognize and take pride in learning a new coping skill today
Session 4
Handout
pg. 6
Session 4: Handout
Smokers that stop without treatment experience nicotine withdrawal.
Remember:
Nicotine is the substance found in cigarettes and other tobacco products that is addicting.
This means that even though you want to stop smoking, your body is used to having nicotine put into it every day.
Your body has become used to having nicotine and wants you to keep taking it even though you know that it
is time to stop.
This is called nicotine addiction or dependence.
Some people choose to stop smoking on their stop day without using NRTs or Pharmacotherapy.
This is often been referred to as “going cold turkey”. This is another stop smoking option.
Session 4
Handout
pg. 7
Session 4: Handout
If you’ve tried to stop smoking or if you’ve tried stopping before and experienced nicotine withdrawal,
think about using nicotine replacement therapy (NRT) or pharmacotherapy to stop.
NRTs or pharmacotherapy to help you stop smoking are safe and effective.
People that use NRTs or Pharmacotherapy to stop smoking have experienced the following:
• They are more as likely to be successful in stopping smoking.
• They don’t experience as many uncomfortable nicotine withdrawal symptoms.
• They have fewer cravings or urges to smoke.
• They feel less depressed after stopping.
• They gain less weight while stopping smoking while taking NRTs.
Session 4
Handout
pg. 8
Session 4: Handout
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Session 4
Handout
pg. 22
Tab Session 5
Session 5:
Getting Ready to
Stop Smoking
E x p l o r e . O p t i o n s . Po s s i b i l i t i e s . Fu t u r e
Getting Ready to Stop Smoking
Review homework from last week: “My Questions About Nicotine Replacement Therapy and
Pharmacotherapy” (Session 4: Handout).
“What if I’m Not Ready to Stop?” (Session 5: Handout) Group discussion
• Ask the group members if anyone is having mixed feelings about stopping smoking.
• Maybe some of the group members are having feelings like they are not ready to stop.
• Maybe some of the group members are having feelings that stopping smoking would be the right thing
to do, but feel scared about what it will be like.
• Why is it important to keep an open mind and explore your options?
• Even if you do not stop smoking during the program, maybe learning new skills around stopping will help
for the future.
Read Goodbye Letter (Session 5: Handout)
“It is Possible for Me to Stop Smoking” (Session 5: Handout) Group discussion
• What are some reasons that people find it difficult to stop smoking (i.e. stress, friends, addicted)?
• Everyone is unique (like snowflakes), so different methods may work for different people and each person
may have different challenges.
• Discussion around managing your time (one day at a time).
• Why is it important to learn new skills to deal with stress?
Session 5
pg. 1
Being fully prepared is a very important part of stopping smoking. It is also important to understand why you
smoke, your smoking patterns and lessons from past attempts.
Is It Worth It? Group discussion and flip chart
• What are some reasons why I keep smoking?
• What are some reasons I want to stop smoking?
Homework: “Is It Worth It?” (Session 5: Handout)
Closing: “3 Deep Breaths” (see Session 1: Handout)
Session 5
pg. 2
regular meals.
reading a book.
Session 5
Getting Ready to Stop Smoking – Patient/Client Weekly Checklist
pg. 3
Session 5: Handout
Some people who smoke may still be feeling unsure about wanting to stop smoking.
• It is very common to have mixed feelings about stopping.
• You may want to continue smoking or you may feel unready to give it up.
• You might be thinking that stopping smoking is the right thing to do, but feel scared about what it will
be like.
• Some of you may want to drop out of this program or group because of uneasy feelings or the pressure
to stop smoking.
The feelings and situations described above are extremely common for people who smoke. It is likely that
you have experienced one or more of them in the past. It is important to keep an open mind and explore
this program.
Even if you are unable to stop smoking at this time, learning more about your smoking is an important step
toward a healthier lifestyle. You may choose to stop someday in the future.
In addition, there are other steps you can take, while you are still smoking, that may be helpful to you.
Session 5
Handout
pg. 5
Session 5: Handout
Some people find it helpful to write a goodbye letter to their addiction during the recovery process.
This might help acknowledge the grief you are feeling and give you the opportunity to express how you
truly feel about the cigarettes you are addicted to. Check out the sample!
Dear Cigarettes,
It is over between us, this time for good. Looking back, I realized that I was wrong about you, and about
who was in control in our relationship. You always had it your way; now I realize that I can’t afford to be with
you anymore.
We’ve had a long relationship; in fact, ours is one of the longest-lasting relationships I’ve had in my life –
we’ve been together off and on for 35 years now. I know we’ve had our ups and downs, and there were times
when I put you out of my life for a time; our longest break-up was over three years, but I’ve come back to you;
you have an almost irresistible quality for me, and you’ve been faithful. I could always count on you being there
in a moment of crisis, you were there by my side, through the good times and the bad.
I remember when we first met; it was in an alley, out of sight of the grown-ups, after all, I was only 10 years
old. I shouldn’t have been seeing you at all. I was proud to let everybody know you were my friend. Pretty soon,
I couldn’t imagine going anywhere without you. In fact, I started to avoid going anywhere where you weren’t
also welcome. How dare they tell me I couldn’t bring my friend along. I can’t remember why, but after we’d
been together around a dozen years, I decided to leave you. Who knows, maybe the relationship had grown
stale. I got over you pretty quickly and soon I didn’t even think of you at all. You waited faithfully for me to
come back to you and a little over three years later, that’s just what I did. I went to my co-workers who I knew
smoked what used to be my brand and asked him for a cigarette. I smoked it, and thought, “This is ok, I can
just smoke this one, and it doesn’t have to mean that I’m a smoker again.” But the next day, almost first thing in
the morning, I went back to that same co-worker and asked him for another cigarette (which he gave me, and
which I smoked). On my lunch hour that day, I went and bought a pack. We picked up right where we left off.
But that’s all over now, you’ve betrayed me. All the time I thought you were my friend, you were secretly
working behind my back to make me sick, to take away my health, my enjoyment of life. I couldn’t believe
you’d ever do any of those bad things to me – after all, we’ve been friends almost all my life. Now I see that I
was wrong.
You always had it your way, now I realize that I can’t afford to be with you anymore. Oh, I’ll miss you for a
while, no doubt, but I’ll get over it and every day I’ll remind myself of what you’ve done to me and what you
would have done if I’d allowed you to stay in my life.
Goodbye.
Session 5
Handout
pg. 4
Session 5: Handout
Many people who smoke use smoking to cope with the stresses and problems of everyday life.
• It’s hard for people who smoke to think of a life without smoking until they learn new ways to
manage stress and problems.
• Remember that different methods work for different people. What may seem silly to others may
be just what you need to stop, so don’t be embarrassed to try something new.
• Pick coping strategies that makes sense to you and then follow through by practicing it.
It will get easier the more you practice.
• When you are feeling stressed, use your new coping skills.
• When you are ready to stop smoking, new coping skills will give you a much better chance of success.
Important Point to Remember:
Many people who smoke believe that stressful situations and problems in life are the reason that they smoke.
It is important to recognize that when your body withdraws from nicotine, you may feel anxious and stressed
and want to smoke. After a short time, these feelings will go away. Don’t confuse withdrawal symptoms,
with stress.
Session 5
Handout
pg. 6
Session 5: Handout
Is It Worth It?
Reasons to Keep Smoking
Reasons to Stop Smoking
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________ ____________________________________________ ____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________
____________________________________________ ____________________________________________ ____________________________________________
____________________________________________
What do you think your challenges are going to be?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 5
Handout
pg.It?
7
Is It Worth
Tab Session 6
Session 6:
My Stop Plan
Prepare.Decide.Share.Commit
My Stop Plan
Review homework from last week, “Is It Worth It?” (Session 5: Handout). Ask patients/clients to share
their ideas.
“Making the Decision to Stop” (Session 6: Handout) Group discussion
• What are your thoughts or feelings around setting a stop date?
• Why is it important to set a stop date? Discussion on the importance of setting a date in the near future,
allowing for time to rationalize and prepare.
• Will you reduce prior to your stop date?
• It is important to take the time to pick the right stop date.
“Suggestions” (Session 6: Handout) Group discussion
Once you have made a decision to stop and have set a date, what are some strategies that will help you stop as
part of your stop plan?
“Life as a Non-Smoker” Group discussion (Session 6: Handout)
“I Will Set a Stop Day” (Session 6: Handout)
• Discuss how important it is for patients/clients to think about their stop plan and make a commitment to
themselves to follow it.
• Remind them that the plan can be changed to include different ways they will reduce stress, deal with
withdrawal and who they will turn to for support.
• Discuss any anxiety that patients/clients may have about picking a stop date and encouraging them to
talk about them with their health care provider or mental health worker.
• It is important to have a plan that includes how they will prepare for the stop day.
• The more planning the better.
Session 6
My Stop Plan
pg. 1
“Barb Tarbox Video” http://www.youtube.com/watch?v=XqQy6qeBpAE
Preamble: If anyone has experienced a resent loss or feel very emotional at this time you may consider
watching the video at a later date. Debrief is absolutely necessary after watching this video.
Read prior to showing video – Barb Tarbox: A Life Cut Short by Tobacco
In September 2002, Barb Tarbox was diagnosed with incurable lung (stage 4) and brain cancer at the age of 41.
Barb Tarbox:
• Smoked two packs of cigarettes a day since the age of 11 years.
• Smoked for 30 years.
• Died May 18, 2003 after speaking to more than 50,000 students about the dangers of smoking.
This video contains strong emotional material regarding Barb Tarbox’s experience with terminal lung cancer
caused by smoking. This is a very powerful, emotional and courageous video. We hope it will give others the
motivation to stop smoking.
View video and debrief/discuss:
• How did the video make you feel?
• What message was Barb Tarbox sending?
• Any other questions and/or concerns?
Homework:
• Complete “My Stop Plan” and “Planning for My Stop Smoking Day”. (Session 6: Handout)
• We will address the questions and/or concerns in the next session.
Note: Prepare Self-Help Kits to give out in session 7.
Session 6
My Stop Plan
pg. 2
regular meals.
reading a book.
Session 6
My Stop Plan – Patient/Client Weekly Checklist
pg. 3
Session 6: Handout
Making the Decision to Stop
The first step is making the decision to stop tobacco use. This is one that only you can make. Other people may
want you to stop, but the real decision and commitment must come from you.
Setting a Stop Date
Once you’ve made the decision to stop, you’re ready to pick a stop date. This is a very important step. Pick a
specific day within the next few weeks as your ‘Stop Date’. Picking a date too far in the future allows you time
to rationalize and change your mind. But be sure to give yourself enough time to prepare what you need to do
to stop and come up with a plan. You might want to choose a date that has a special meaning like a birthday
anniversary or holiday. Or you can simply pick a random date. Circle the date on your calendar and then make a
strong, personal commitment or promise to yourself to stop on that day.
Making a Stop Plan
Once you have made a decision to stop and have set a stop date, developing a list of other strategies that will
help you stop is all part of your stop plan. Preparing yourself and your surroundings before you stop will make
it easier for you to achieve your stop goal.
Citation: From the Learning about Healthy Living Manual. Williams JM et. al. State of New Jersey, Division of Mental Health Services.
Revised June 2005.
Session 6
Handout
4
Making the Decision to pg.
Stop
Session 6: Handout
Suggestions (Can be used as homework)
Get rid of ALL of your matches, lighters and ashtrays.
Make a promise to yourself to NEVER SMOKE in your house or car.
Talk to your doctor and counsellor about stopping smoking.
Pick a person who you can talk to and be helpful to you.
Learn about tobacco treatment medications and decide which ones you may want to use.
Get support from non-smoking friends and family.
Make a list of situations that you would usually smoke and come up with a plan of how you will handle those
situations differently.
Revised June 2005.
Session 6
Handout
pg. 5
Suggestions
Session 6: Handout
Did you know that athletes use their imagination to win medals? For example, Laurie Graham (downhill
skiing) and Donovan Bailey (sprinting) both spent time imagining perfect performances. When it was time to
complete, they turned their imagery into the real thing.
Imagery is not the same thing as fantasy. When athletes imagine their performances, they make the image as
real as they can. They think about what they are wearing and who is with them, how their equipment feels,
how loud the crowd is, and even how nervous they feel.
So, how does this relate to stopping smoking? If you can imagine yourself as a non-smoker, then you can be one.
There is a part of you that is a non-smoker already. The more you focus on that, the bigger and stronger that
non-smoker becomes.
Can you imagine?
•
•
•
•
What it will be like to go for a day, a week, or a month without a cigarette?
How you will feel emotionally and physically?
How others will respond as you quit smoking?
What you will do instead of smoking a cigarette?
Take your time – spend 5 – 10 minutes imagining yourself as a non-smoker. Do this activity 3 times a week for
a few weeks.
Use these tips to make your imagination work for you.
• Relax with the deep breathing techniques from session 1 before you begin your imagery.
• Make your images real. Don’t just fantasize. Imagine that what you are thinking, feeling, seeing and
hearing is true.
• Believe in your image and take it seriously.
Try to practice. Imagining is a skill you can develop.
Have you done the activities?
Even if you’re in a hurry to stop smoking, it is a very important to stop and follow these activities. Doing them
now will help you resist the temptation to smoke later. It can help you to make this important change in your
life a success.
Remember, former smokers say that stopping is easier if you:
•
•
•
•
Know why you smoke.
Practice stopping before your final stop date.
Know what side effects and other changes to expect after stopping.
Learn to deal with cravings and temptations.
By preparing yourself to stop, you’ve taken a giant step toward being a non-smoker. Stopping might take as
much time as developing the habit in the first place. However, this plan has worked for thousands of others
and it can work for you.
Citation: Adapted from For Smokers Who Want to Quit – Canadian Cancer Society, pg 42, 43
Session 6
Handout
pg. 6
Session 6: Handout
I Will Set a Stop Day
One or two weeks before my stop date, I will:
• Pick the date and mark it on my calendar.
• Tell friends and family members that I will stop smoking.
• Decide a plan for medications and arrange to see my doctor.
• Set up a support system. This could be my group class, or a non-smoking family or friends who are
willing to help me.
On the night before my stop date, I will:
• Get rid of all cigarettes, lighters, ashtrays, and any other items related to smoking.
• Smoke my last cigarette and say “goodbye” to cigarettes.
On my stop date, I will:
• Not smoke.
• Keep active – try walking, exercising, or doing other activities or hobbies I enjoy doing.
• Drink water and use mints or hard candy to help me with the cravings for cigarettes.
• Begin using nicotine medications if that is part of my stop plan.
• Avoid other people who smoke.
• Avoid places and situations where the urge to smoke is strong.
Session 6
Handout
8
I Will Set a Stoppg.
Day
Session 6: Handout
My Stop Plan
Name ___________________________________
I have made a decision to stop smoking on _______________
As part of my plan to stop smoking, I will: (check all that apply)
Come to treatment sessions to talk about tobacco.
Read handouts.
Talk to other people who used to smoke and learn about how they were able to stop.
Make a list of all the reasons I want to stop. I will carry this with me in my pocket as a reminder.
Begin to make smoking more difficult and more unpleasant for myself. This means not smoking my
favourite brand, not smoking in my favourite places and going outdoors to smoke.
Save the money I used to buy cigarettes to do something or buy something special for myself.
Each week, I will save $ __________
I will use the money to: __________________________
My “Support Person” will be: _______________________
He/she will help me to stop and remain without tobacco. Instead of smoking, I will try to talk to this person
when I feel like I want a cigarette.
Make an appointment with my doctor to talk about tobacco treatment medications.
Other ideas for my stop plan:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 6
Handout
7
My Stoppg.
Plan
Session 6: Handout
Planning for My Stop Smoking Day
I will set a stop day.
One to two weeks before my stop date, I will:
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
5.__________________________________________________________________________________________
On the night before my stop date, I will:
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
4.__________________________________________________________________________________________
On my stop date, I will:
1.__________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
5. __________________________________________________________________________________________
6. __________________________________________________________________________________________
7. __________________________________________________________________________________________
Session 6
Handout
9
Planning for My Stop Smokingpg.
Day
Tab Session 7
Session 7:
Withdrawal
Question.Char t.Encourage.Network
Withdrawal
Review homework from last week, “My Stop Plan” and “Planning for My Stop Smoking Day”
(Session 6: Handout).
“Triggers: Internal & External” (Session 7: Handout)
Group Discussion: “Triggers are Different Than Cravings” (Session 7: Handout)
• Pair patients/clients together and ask them to work on the handout. Discuss responses as a group.
If patients/clients are not comfortable in pairs, discuss as a group.
within 4 meters of windows, air intake vents and entrances to places of employment. Encourage clients not
to smoke during breaks as the smell of smoke on their clothes affects/triggers others and it is a good idea to
practice being smoke free.
“Coping Withdrawal/Recovery Symptoms” (Session 7: Handout) Group discussion
What are the 4 D’s (Delay, Deep Breathing, Drink Water, and Do Something different). Have on flip chart to
display each week.
“4 D’s Magnet Template” (see Appendix A: Session 7: Resource) “4 D’s” (Session 7: Handout)
• How can you deal with physical cravings?
• How can you deal with your moods and/or emotions?
• What can you do with your hands to keep busy?
• How do you deal or avoid triggers?
• What about networking and building supports
Session 7
Withdrawal
pg. 1
“Becoming a Non-Smoker – What’s in It for Me?” (Session 7: Handout) Group discussion and flip chart:
• What are the benefits to you for becoming smoke free?
• “101 Things to Do Instead” (Session 7: Handout)
“Walking on a Beach Guided Imagery” to be read by a facilitator (see Appendix A: Session 7: Resource)
“Self-Help Kits” – pass out bags and go through contents with clients.
Homework “Triggers and Cravings” (Session 7: Handout)
• What are some techniques you are using to help with cravings and triggers?
• List your possible internal triggers.
• List your possible exterior triggers.
• List your supports.
Session 7
Withdrawal
pg. 2
regular meals.
reading a book.
Session 7
Withdrawal – Patient/Client Weekly Checklist
pg. 3
Session 7: Handout
What are you usually thinking about right before you would smoke?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
What are you usually feeling physically right before you would smoke?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
What are you usually feeling emotionally right before you would smoke?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
It is so important to know your triggers, and plan ahead before triggers happen!
Session 7
Handout
pg. 5
Session 7: Handout
Cravings
For most tobacco users, tobacco cravings or urges to smoke can be powerful. Your crave cigarettes because
you are addicted. When an urge to use tobacco strikes, remember that although it may be intense, it will be
short-lived, and it probably will pass within a few minutes. Each time you resist a tobacco craving or urge,
you’re one step closer to stopping smoking. But it can be difficult. Delaying, avoiding triggers, yoga and
nicotine replacement are among the ways to resist cravings.
Triggers
Triggers are times, places, situations, feelings and emotions that trigger your urge to smoke, i.e. seeing your
cigarette package or smelling another person’s cigarette smoke are powerful triggers.
Withdrawal Symptoms
Most nicotine from smoking is flushed from your body after an average of 4 to 5 days. The withdrawal
symptoms start during the first day and peak on the second or third day. They usually subside the fourth week.
Why do some people feel worse after they stop smoking and how can you deal with these things?
Headaches, nervousness or irritability:
Do some relaxation exercises or listen to your favourite music. If your headache gets too bad, ask your doctor
or health care professional to recommend a pain reliever. Drink lots of water and juice to flush the nicotine out
of your body faster.
Trouble sleeping:
If you smoked to relax, you may have trouble sleeping after you stop. Eliminate or reduce caffeine (coffee, tea,
cola, chocolate) from your diet for a while. Also, slow down towards bedtime. Reading or watching TV is better
than physical activity.
Constipation:
Stopping smoking changes your daily routine and may make you irregular. Eat more vegetables and fresh fruit.
Eat a high-fibre cereal each day for breakfast. Be sure to drink plenty of water and juice.
Cough:
You may cough a bit more than usual, shortly after stopping smoking. Your lungs are cleaning themselves out.
If it gets bad, try cough drops to soothe your throat.
Dizziness:
Stop and sit down a moment. It should pass in a few seconds.
Changes in appetite:
This can be from changes occurring in your brain, your increased ability to smell and taste food, the need to
have something in your hands and mouth, or all of these things. Before you eat, ask yourself whether you really
need to eat or if you just want to be distracted. Instead of eating, go for a short walk or call a friend. When you
do eat, make sure it is healthy food that is low in fat and high in fibre.
Session 7
Handout
pg. 4
Session 7: Handout
Common Symptoms
Tips to Cope
Physical Cravings
•
•
•
•
•
•
•
•
Deep breathe
Delay
Do something else
Drink fluids
Remind yourself of the benefits of stopping, and supports available
Focus on your goal and the small steps that you can take to reach it
Think positively – you can do it!
Identify and avoid triggers to smoke
Cranky, Moody, and Tense
•
•
•
•
Deep breathe
Listen to relaxation tape
Have a warm bath
Do some physical activity (go for a walk)
Can’t Concentrate
Restlessness
•
•
•
•
•
•
Tell yourself “it will pass”
Do something that doesn’t need as much thinking
Set your goals
Shake out your arms and legs
Have a warm drink
Do some physical activity
Coughing
Tingling Fingers and Itching Scalp
• Think positively – your lungs are starting to clean themselves
properly again
• Think positively – this is a sign that your body is starting to recover
(more oxygen in your bloodstream)
• Increase your physical activity
Hungry
Putting on Weight
•
•
•
•
Change in Sleep or
Disturbed Sleep Pattern
• Get into a routine of going to bed at the same time each night
• Do calming, soothing things at night (eg. music, warm drink,
relaxation tape)
• Tell yourself “this will pass”
• Keep active during the day
• See doctor if sleep problems continue
Eat low fat, high fibre food and snacks
Increase activity to balance extra food intake
Avoid high calorie food intake
Drink fluids (non-caffeine, non-alcohol)
Remember that some symptoms may also be due to side effects of your medication.
You should continue to see your doctor regularly.
Session 7
Handout
pg. 7
Session 7: Handout
Becoming a Non-Smoker – What’s in It for Me?
When you find yourself worrying about stopping and wondering why you would even want to do so,
try thinking positively about the benefits of not smoking.
• I will have more spending money.
• My risk of heart attack will be lowered.
• My risk of developing bronchitis or emphysema will be reduced.
• My risk of earlier death will be reduced.
• My circulation will improve as I have more oxygen in my blood.
• I will get fewer colds.
• I will have more energy.
• My body will rid itself of carbon monoxide.
• My muscles will not tire as easily.
• My clothes and hair will no longer smell of tobacco smoke.
• I will no longer feel I need to have a “smoke break”.
• I will have two free hands again.
• My throat won’t be irritated.
• My taste buds will come back to life.
• My sense of smell will improve.
• I will look better and healthier with good colour in my cheeks.
• I will not have to monitor my smoking.
• My risk of developing an ulcer will be reduced.
• I will be able to say “No thanks, I don’t smoke”.
• I will have less chance of developing wrinkled skin.
• I will reduce the risks of asthma attacks.
• I will no longer be a bother or harm to those around me by smoking.
• I will feel I have won a battle against a highly addictive substance.
• My risk of cancer – lung, throat, mouth, stomach, bladder, and pancreas will be reduced.
• ____________________________________________________________________________________
• ____________________________________________________________________________________
Session 7
Handout
6
Becoming a Non-Smoker – What’s in It forpg.
Me?
Session 7: Handout
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Read a book
Wash a car
Go for a walk
Knit a scarf
Wash the dog
Do a crossword puzzle
Take a nap
Call a friend
Post a message
Play with the cat
Turn the bathroom into a spa and do all
those beauty treatments
Listen to relaxation tape or some favourite music
Go to a store and get a free make-up session
Give yourself a manicure and pedicure
Try out a new hair-do
Chew some cloves
Go to the movies
Do a jigsaw puzzle
Breathe deeply
Hang out at the mall
Drink some ice water
Jump on a treadmill or go to a gym
Give someone you love a huge hug
Plant some flowers
Do some exercise – swimming, aerobics,
yoga, etc. (feel good factor) and relieving
stress (physical & mental)
Work out how to post a picture on your
computer
Take up a new hobby/interest – channel your
thoughts into something constructive and
interesting
28. Work in the garden
29. Retail therapy with the cash you saved from
not smoking
30. Suck on a piece of tart candy
31. Slather on a rich, creamy hand lotion and rub,
rub, rub! It keeps fingers busy, and reminds you
how nice it is not to have tobacco stink on them
32. Eat a popsicle
33. Floss and brush your teeth
34. Make out with your special someone.
Hubby hated kissing me when I smoked, but now
he loves it. So, when the urge strikes and he’s
within kissing distance, I plant a big one on him
35. Chew gum
36. Chew a toothpick
37. Spend time with your children
38. Give yourself a treat every day no matter
how small
39. Spend an hour filling the paddling pool in
the garden on a gorgeous sunny day
40. Play several games and hopefully win one
41. Walk in an old graveyard with someone you love
42. Get your jammies on early, and park yourself
in front of the TV or computer for the night
43. Clean your closet
44. Tidy your cupboards
45. Walk the dog
46. Paint a picture
47. Clean under the sink
48. Draw a picture
49. Hang on dearly to a caramel apple sucker
50. Sing loudly
51. Practice smiling in the mirror
(releases endorphins)
52. Make a list of pros and cons of smoking
Session 7
Handout
pg. 8
Session 7: Handout
101 Things to Do Instead of Smoking (con’t)
53.
54.
55.
56.
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
Find gross smoking disease pictures
Play with silly putty
Whistle “Don’t worry, be happy”
Get a camera and take some pictures
Write a letter (you know… on paper)
Clean out the closets
Crank up the radio and sing at the top of your
lungs (works great for driving away cravings)
Crank up the radio and dance like no one
is watching
Make a puzzle
Organize your box of photos
Alphabetize your CD rack
Do some scrap-booking
Go to miniclip.com and play games
Do your nails. Hard to smoke with wet nails
Take a shower
Take a candle lit bath
Clean out a messy drawer
Take a day trip
Try making home-made candles or soap
Run in place
Do some jumping jacks
Start a reward fund – put away the amount of
money you spend on smokes every day and use
it to treat yourself once in a while
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
Write poems
Go antique shopping
Go plant a flower for every negative thought
Go to church/talk to God
Let your partner cook supper for you
Call your grandmother
Skip a rope
Eat a hot fudge sundae
Go play mini-golf
Clean the basement or garage
Wax the car
Play “I Spy” with your children
Scrub the floor
Treat yourself to a massage
Chop up some veggies for a stir fry,
keep your hands busy
90. Clean out the litter box
91. Check your car’s tire pressure
92. Call a radio show and request a song
93. Go ride a few rollercoaster’s
94. Take a walk in nature
95. Write a goodbye letter to cigarettes
96. Watch the sun set
97. Donate blood
98. Colour your hair
99. Make a greeting card
100. Write a list of things you are grateful for
101. Run around in the sand in your socks
Session 7
Handout
pg. 9
Session 7: Handout
List your possible internal triggers (feelings and emotions).
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
List your possible exterior triggers (people, places, things or events).
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
What are some techniques you are using to help with cravings and triggers?
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
List your support.
1. __________________________________________________________________________________________
2. __________________________________________________________________________________________
3. __________________________________________________________________________________________
4. __________________________________________________________________________________________
Session 7
Handout
pg. 10
Tab Session 8
Session 8:
Changing
Negatives
Into Positives
T h i n k . Te c h n i q u e s . I m a g i n e . R e s u l t s
Changing Negatives Into Positives
• Has anyone used the 4D’s since the last session?
Review homework from last week: “Triggers and Cravings” (Session 7: Handout) Group discussion and flip chart
• List your possible internal triggers.
• List your possible exterior triggers.
• What are some techniques are you using to help with cravings and triggers?
• List your supports.
“Lemon Guided Imagery” to be read by a facilitator (see Appendix A: Session 8: Resource)
• We need to use our imaginations for the exercise.
• Everyone is asked to close their eyes, remain quiet and listen carefully.
• This is only a 2 minute exercise.
• Following the guided imagery have group discussion about what the clients felt during and after the exercise.
within 4 meters of windows, air intake vents and entrances to places of employment. Encourage clients not
to smoke during breaks as the smell of smoke on their clothes affects/triggers others and it is a good idea to
practice being smoke free.
Session 8
pg. 1
“Changing Negatives Into Positives” (Session 8: Handout) Group discussion or pair two patients/clients
together and get them to work on the handout. “Pressures to Smoke and What to Do?” (Session 8: Handout).
Remind patients/clients they do not have to write down the information, just bouncing ideas off each other
can help.
There is a connection between how a person thinks (positive or negative) and this has an effect on feelings and
emotions, and may result defeating cravings or giving into them.
Group discussion on results of the handout: “Sample Responses” (see Appendix A: Session 8: Resource)
Homework: “Pressures to Smoke and What to Do?” (Session 8: Handout)
Session 8
pg. 2
regular meals.
reading a book.
Session 8
Changing Negatives Into Positives – Patient/Client Weekly Checklist
pg. 3
Session 8: Handout
Sometimes our negative thoughts can stop us from doing what we need to do. Try to change these negative
thoughts to ones that will help you feel good about trying to change your smoking habits.
Negative Talk
Positive Talk
“Smoking is my only
real pleasure.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
“I have nothing better to do.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
“Cigarettes are part of my life,
and I’ll panic without them.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
“All my friends smoke.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
“I have to smoke to cope
with the stress in my life.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
“I’ve tried before and failed,
it’s too hard to stop.”
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
______________________________
______________________________
______________________________
______________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Session 8
Handout
pg. 4
Session 8: Handout
Pressures to Smoke and What to Do?
Pressures to smoke can come from feelings and thoughts you have. Write some of the pressures you feel in the
left hand circle and in the right circle, write a way to deal with the pressure.
Pressures to Smoke
From inside me…
What to Do
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
From the world outside me…
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Session 8
Handout
5
Pressures to Smoke and What topg.
Do?
Tab Session 9
Session 9:
Stress
Calm.Mindful.Relaxation.Insight
Stress
Group Member Check-in (10 – 15 minutes)
Review homework from last week: “Pressures to Smoke and What to Do?” (Session 8: Handout)
“What Is stress?” (Session 9: Handout) Group discussion and review of handout.
• What is stress?
• What are the types of stress?
• What are some things that can bring on stress?
“The Stress Response” (Session 9: Handout) Group discussion: Review the stress responses on the handout
with the group.
• How do you feel physically when you are stressed?
• How do you feel emotionally when you are stressed?
• How does stress affect your thinking?
• What types of decisions do you make while you are stressed, healthy or unhealthy?
“How Do Cigarettes Cause Stress on the Body?” (Session 9: Handout)
“Positive Changes Your Body Goes Through When You Stop Smoking” (Session 9: Handout)
“The Relaxation Response” (Session 9: Handout) Review the relaxation responses with the group.
Group discussion – sample questions.
• How do you physically feel when you are relaxed?
• How do you feel emotionally when you are relaxed?
• How is your thinking and decision making ability while you are relaxed?
Session 9
Stress
pg. 1
“How Can I Manage Stress?” (Session 9: Handout) Work on handout as a group with the flip chart.
Group discussion:
• What can you do physically?
• What can you do about your feelings and emotions?
• What could you do about your thinking and decision making?
Homework “What is Stress?” (Session 9: Handout). Ask patients/clients to complete the My Stressors are…
section of the handout and think about responses on the “How Can I Manage Stress?” (Session 9: Handout)
“Exercise: Deep Breathing” (Session 9: Handout)
Session 9
Stress
pg. 2
regular meals.
reading a book.
Session 9
Stress – Patient/Client Weekly Checklist
pg. 3
Session 9: Handout
What is Stress?
• Stress is a change that we have to adapt to.
• Stress comes from both good and bad things that happen to us.
• When we are not sure how to handle these events or situations or how they will work out, we worry and
feel stressed.
• Stress is a fact of life. No matter how much we might want a stress-free life, stress is actually necessary.
• Some stress gets us going and gives us things to do (i.e. a list of things to do).
• Other stress makes us feel like we are overloaded and unable to cope (i.e. lots of bills to pay).
• It is how we respond to stress that can negatively affect our lives.
• The things that cause one person stress may not cause another person stress. Your reaction to stress
affects your health, both mentally and physically.
My stressors are…
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 9
Handout
pg. 5
What is Stress?
Session 9: Handout
What is Stress? (con’t)
Did you know that cigarettes could actually cause you to be tense and ADD to the STRESS in your life?
Smokers believe that when they have a cigarette, it eases the feelings of anxiety or restlessness that they are
feeling. As we learned earlier, these same feelings of anxiety and restlessness are caused from withdrawal (or
not having a cigarette because the body needs one).
Smokers often mention stress as a reason keeping them from stopping.
Smokers have learned to use tobacco to help cope with stress. Remember… Smoking and stress do not have to
go hand in hand. There are other healthy things you can do to make yourself feel better!
Cigarettes will not take away your problems.
• Smoking will usually only add to the problems you already have.
When you stop, you have to learn new ways of handling stress.
• Physical activity and healthy eating can help to reduce stress.
• Making sure that you have time to do the things you like to do is very important.
• Sometimes writing down your feelings and frustrations will help to relieve stress.
• Making a “to do” list each day can also be very helpful. As you complete them, check them off and you will
see everything that you accomplished. This technique helps you to remember and will also take away the
stress of worrying to remember to do them.
• For some people, being outside in nature is helpful. Sitting at a park or on a beach can be very relaxing.
Sometimes just closing your eyes and imagining that you are at your favourite place can be relaxing.
• Consider learning specific stress reduction skills such as mindfulness, meditation and yoga. Also consider
alternative therapy such as acupuncture and recreational activities.
Session 9
Handout
pg. 6
What is Stress?
Session 9: Handout
The Stress Response
Crying & mood swings
Tense muscles
Headache
Stomach upset & diarrhea
Poor memory
Flushed face
Frequent illnesses
(e.g. cold & flu)
Sweaty palms
Racing heart &
high blood pressure
Shortness of breath
Strong emotions are accompanied in varying degrees by the physical and psychological sensations of the
stress response. The stress response protects us in times of real physical danger by preparing the body for
action, but it can be just as strong in times of mental or emotional stress.
Session 9
Handout
pg. 8
The Stress Response
Session 9: Handout
How Do Cigarettes Cause Stress on the Body?
Smoking hurts your lungs. It damages your lungs’ natural cleaning and repair system and traps cancer-causing
chemicals in the lungs.
When your lungs’ natural cleaning and repair system is damaged, germs, dirt and chemicals from cigarette
smoke stay inside your lungs. This puts you at risk for chronic cough, chest infections, lung cancer and COPD
(chronic obstructive pulmonary disease).
Smoking increases your heart rate and blood pressure and increases the workload of the heart.
People who smoke are at high risk for many diseases, some include:
• Chronic obstructive pulmonary disease
(COPD, including emphysema and chronic bronchitis)
• Lung cancer and cancer of the mouth, lip, throat,
and voice box
• Pancreatic, breast, cervical, stomach, liver, kidney,
and bladder cancer
• High cholesterol (LDL)
• Pneumonia
• Influenza (the “flu”)
• The common cold
• Peptic ulcers
• Leukemia
• Tooth decay (cavities)
• Coronary heart disease (e.g. heart attacks)
• Gum disease
• Circulatory problems
• Osteoporosis
• High blood pressure
• Sleep problems
• Cataracts
Remember from Session 2, many of the health effects and risks of smoking are reduced when you
stop smoking.
Citation: Adapted from www.lung.ca
Session 9
Handout
11
How Do Cigarettes Cause Stress on the pg.
Body?
Session 9: Handout
Today your body starts to heal from the damage caused by smoking. You will probably feel both good and bad
at different times, but your body heals quickly if you give it a chance.
8 hours after quitting:
There is more oxygen in your system and your blood pressure begins going down. Your body feels like a heavy
weight has suddenly been lifted.
After 1 day:
Your lungs are working better and you don’t feel quite so out of breath. You can climb the stairs more easily.
After 2 days:
Your senses of taste and smell are returning. You’ll be coughing more as your lungs get rid of mucus.
After 1 week:
The blood flow to your hands and feet will improve and you won’t feel as cold.
Within ½ a year:
You will notice less coughing, sinus congestion and shortness of breath.
After 1 year:
Your risk of dying from a heart attack is cut in half.
Citation: Adapted from One Step at a Time for Smokers who want to Quit Smoking
Session 9
Handout
pg. 12
Session 9: Handout
Clear thinking
Sense of calm
Relaxed muscles
Lower heart rate &
blood pressure
Slow deep
breathing
Comfortable digestion
Boosted immune system
Contented feelings
Less frequent illnesses
(e.g. cold & flu)
Achieving a deep relaxed response is a learned skill. By setting aside 15 to 20 minutes in your day to deeply
relax, you can regularly renew physical and emotional energy and bring a fresh perspective.
Session 9
Handout
pg. 9
Session 9: Handout
Are you feeling stressed out?
First of all, it is important to know that STRESS is a part of life! How YOU CHOOSE to deal with your stress is what
we want to think about. Some people yell and scream when they are stressed out. Others may hide in their
rooms and cry. Some people will eat, smoke or drink when they are under stress. However you choose to deal
with your stress… BE SURE THAT WHAT YOU DO IS REALLY HEALTHY AND HELPFUL!
A good way to cope is to learn skills to help you relax.
DEEP BREATHING
We will teach you the skill of deep breathing to help you relax. Many times, people take short breaths when
they are under stress. This does not give your body the proper amount of oxygen it needs. Remember that
smoking also takes away the good oxygen that it needs.
Learning deep breathing exercises makes you feel relaxed by breathing slowly and giving your body more
oxygen. This skill takes 3 to 5 minutes to do. It involves both your chest and stomach muscles. While doing this
exercise, try to focus on the sound and feel of your breathing.
Session 9
Handout
pg. 4
Session 9: Handout
What can you do physically?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What can you do about your feelings and emotions?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What can you do about your thinking and decision making?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 9
Handout
pg. 7
Session 9: Handout
Practice Deep Breathing for the next 3 to 5 minutes.
1. Sit in a chair, arms at sides, feet uncrossed.
2. Note any tension or tightness in your muscles.
3. Put one hand on your chest and your other hand on your stomach.
4. Take a slow, deep breath through your nose. As your lungs fill, your stomach should raise first and
the chest next.
5. Hold the air in for three seconds.
6. Blow the air out through your mouth, making a whooshing sound.
7. Keep taking long, slow deep breaths in through your nose and letting long slow breaths out
through your mouth.
8. Focus on the sound of your breath. Do this for 3 to 5 minutes.
How do you feel after practicing the deep breathing exercise?
Was it hard for you to do the exercise? Sometimes people who smoke have a hard time doing this exercise
and will begin to cough. You will find that if you stop smoking, it will be easier to do as well as practicing this
exercise every day.
Session 9
Handout
pg. 10
Tab Session 10
Session 10:
Stress Relief
Ac tivities.Build.Energy.R esistance
Stress Relief
Review homework from last week: “What is Stress”, “My Stressors Are…” (Session 9: Handout)
“The AAABC’s Stress Management” (Session 10: Handout) Review and discuss.
• Alter – remove the source of stress by changing something.
• Avoid Stress – skills around – walking away, letting go, assigning other tasks, or knowing your limitations.
• Accept the stress by Building Resistance, what does that mean?
ūū What can you do physically, mentally, socially, and spiritually to build resistance to stress?
• Change the way you look (point of view) at the stressor.
Practicing Stress and Tension Relieving Exercises: “Stress Busters and Stretching” and “Tension
Releasing” (Session 10: Handout) Practice several of the relaxing activities with the group.
Session 10
Stress Relief
pg. 1
“Why Do I Smoke? Tips to Help Me Cope” (Session 10: Handout)
1. Smoking gives me energy – We know how smoking negatively affects health. What are other things we
could do to increase energy levels and feel better?
2. I like the feel of cigarette in my hands – what are other things that we can do to occupy our hands?
Ask if patients/clients tried any items from the cope kit.
3. I enjoy it, smoking relaxes me – Smoking does not relax the body. What are some things that can relax
a person (i.e. deep breathing, stretching, talking to a friend or support person)?
4. I depend on cigarettes to lessen my stress – Smoking stresses the body. What are some stress busters
MAPP has covered so far? i.e. deep breathing, stretching, exercise, talking to a friend or support person.
5. I crave cigarettes because I am addicted – How long does a craving last? What can you do to get through
a craving? 4D’s (Drink, Delay, Deep Breathe, Do Something Else)
6. Smoking is a “habit” – Change your routine, get rid of some things that remind you of smoking,
have things ready to keep your hands busy in places where you know you used to smoke.
Homework: “Why Do I Smoke? Tips to Help Me Cope” (Session 10: Handouts [4]).
Session 10
Stress Relief
pg. 2
regular meals.
reading a book.
Session 10
Stress Relief – Patient/Client Weekly Checklist
pg. 3
Session 10: Handout
You have 3 major ways of dealing with stress:
Alter Stress – remove the source of stress by changing something
•
•
•
•
•
•
Time management
Planning
Organizing
Assertive behaviour
Direct communication
Modify demands
Avoid Stress
•
•
•
•
•
•
Walk away
Let go
Say “no”
Delegate other tasks
Withdraw
Know your own limits
Accept the Stress by
Building Resistance
Physically: Adequate sleep
•
•
•
•
Nutritious diet
Regular exercise
Relaxation techniques
Take medications as prescribed
Mentally: Take time for your mental health
• Be clear about your goals, values, and priorities
• Use positive affirmations
Socially: Build Relationships
• Share your thoughts and feelings
Spiritually: Develop your faith
Changing the way you perceive the stressor or yourself
•
•
•
•
Change unrealistic expectations or irrational beliefs
Build your self-esteem
Use humour/keep a positive attitude
Reframe the stressor
Session 10
Handout
pg. 4
Session 10: Handout
Stress-Busters – Activities to Beat Stress!
Counting:
• Close your eyes
• Take a deep breath and hold it
• Slowly count backwards from 10 as you let the air out
Shake the muscles out…
• Shake out your arms
• Shake out your legs
• Bend forward, arms hanging loosely at sides, sway back and forth
• Keep all the body parts loose
Close your eyes…
• Drop your jaw
• Drop your head
• Drop your shoulders
• Feel the tension drop away
Do something else…
Stretching
• Stand up and put one hand on your chest with the palm facing outward.
• Extend your arm forward as if you were pushing something out of the way.
• When you have reached all the way out, turn the hand toward you.
• Draw your arm toward you and bring it to your chest again.
• Repeat this several times very slowly.
• Do the same thing with the other arm.
• Once this is comfortable, begin with one arm out, when it reaches the extension and begins to pull in,
start off the second arm.
More Stretching
Wooden Soldier:
• Stand on toes stretching arms above head
• Bring arms out to the sides
• March around swinging arms like a wooden soldier
• Relax
Shoulder Raises:
• Raise your shoulders and count to 3
• Drop your shoulders backward 5 times
Shoulder Rotations:
• Rotate your shoulders forward 5 times
• Rotate your shoulders backward 5 times
Session 10
Handout
pg. 5
Stress-Busters
Session 10: Handout
Tension Releasing
You can do this wherever you are, whenever you feel the need.
• Let go of the tension in your neck and shoulders.
• Let go of the tension in your jaw.
• Focus completely on your breathing, nothing else.
• As you exhale, let your shoulders drop (relax) and let your body sink (into the chair or the floor).
• Repeat this until you feel relaxed and centred.
Remember, these breathing and relaxing techniques are skills. You have to practice them. Choose the one you
like best and do it 4 or 5 times a day for the next few weeks. When you become good at it, you will be able to
relax quickly and completely, and you will realize that you are reducing your mental and physical level of stress.
You will feel revived, refreshed and ready to go smoke-free.
Session 10
Handout
pg. 6
Tension Releasing
Session 10: Handout
Why Do I Smoke? Tips to Help Me Cope (con’t)
1.Smoking gives me energy (list other ways to boost energy).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
2.I like the feel of cigarette in my hands (list other things you can do).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
3.I enjoy it, smoking relaxes me (list other ways to relax).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 10
Handout
pg. 8
Session 10: Handout
Why Do I Smoke? Tips to Help Me Cope (con’t)
4.I depend on cigarettes to lesson my stress (list ways to deal with stress).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
5.I crave cigarettes because I am addicted (list ways to deal with cravings).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6.Smoking is a “habit” (list skills around breaking habits).
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 10
Handout
pg. 9
Session 10: Handout
1.“Smoking gives me energy”
4. “I depend on cigarettes to lessen my stress!”
Tips to cope:
Tips to cope:
• Drink fruit juice
• Take fresh fruit breaks
• Start exercising
2. “I like the feel of a cigarette in my hand!”
Tips to cope:
•
•
•
•
Draw or doodle
Do word search or jigsaw puzzle
Make a model out of clay
Carry a pet rock, paper clip,
toothpick or stir stick
• Smoke straws
• Cut up veggies
3. “I enjoy it, smoking relaxes me!”
Tips to cope:
•
•
•
•
•
•
•
•
•
Find other things that you enjoy
Go for a walk
Lie down and watch TV
Take up a new hobby
Crochet, knit or paint
Listen to a relaxation tape or relaxing music
Ride on a bus to see where it goes
Rent a movie
Spend time with fun friends
•
•
•
•
•
•
•
•
•
Deep breathe
Exercise – walking, skipping
Keep busy
Do something special for yourself
Take a bubble bath, warm shower
Stretch
Talk to someone about your stress
Socialize, visit with nonsmokers
Avoid alcoholic drinks
5. “I crave cigarettes because I am addicted!”
Tips to cope:
•
•
•
•
Delay or deep breathe
Drink water
Tell yourself “the urge will pass”
Keep cold or flavoured things in your mouth,
tic tacks, ice cubes
• Take up hobbies
• Monitor and plan your strategy
6. “Smoking is an addiction!”
Tips to cope:
•
•
•
•
•
•
Monitor every cigarette
Say “no thanks, I don’t need it”
Socialize with nonsmokers
Take up a new hobby
Delay a few minutes
Talk yourself out of it
Session 10
Handout
pg. 7
Tab Session 11
Session 11:
Being Active
D evelop.Exercise.M ove.Par ticipate
Being Active
• How are patients/clients doing this week?
• Any mood changes or changes in emotion?
• Questions or concerns regarding NRT?
Review homework from last week, “Why Do I Smoke? Tips to Help Me Cope” (Session 10: Handout)
• The following is an additional resource: Health Canada - www.health.gc.ca/eatwell-beactive
“Being Physically Active” – Group discussion: “Physical Activity and Smoking: Key Messages for Patients
and the Public” (see Appendix A: Session 11: Resource)
• Does not mean that you need to join a gym or start jogging! Being active means moving more and
making a conscious effort to keep your body moving.
• Should make you feel good, i.e. improved blood flow to the muscles, improved balance and coordination,
and can reduce lower back pain.
• Can change your attitude towards life. Any type of physical activity will do, just as long as you are active
every day.
• Will help you stop smoking and help your body recover faster from the negative effects of smoking.
• May also help with the temporary “blues” or depression some people feel when they stop smoking.
• Pick the activities you enjoy. Start with stretching, walking, or gardening.
• If you are not active, start slowly and be sure to check with your doctor before starting any
exercise program.
Ask the group for ideas for inexpensive and easy ways to get started being active.
“Activities to Get You Moving” (Session 11: Handout) review.
• Ask group to circle activities that they would like to try.
• Focus on easy and inexpensive ways to be active, especially in the winter months.
• Get up to change the TV channel, walk around the room during TV commercials, dance to music, throw a
tennis ball or sponge ball against the wall, hula hoop, skip rope, lift soup cans, do stretching, park the car
further away and walk a few extra steps a day, make housework fun by playing music and dancing,
buy a Frisbee, call a friend to walk with, or walk your dog.
Session 11
Being Active
pg. 1
“50 Ways to Make Physical Activity Part of Your Life!” (Session 11: Handout) Local opportunities to be active:
highlight local trails, and other low cost opportunities for activity in your area. Some parks have free or low cost
cross country skiing.
• Ask fitness centres, bowling lanes, and your local recreation department about subsidized memberships
or drop in rates.
• Check the local library for books, or DVDs on loan.
• Ask group if they know of events or opportunities in the area that they would like to take part in.
Break: Reminder of smoking policy for the building and grounds, in the back at least 4 meters from the main
building. Encourage patients/clients not to smoke during breaks as the smell of smoke on their clothes affects/
triggers others and it is a good idea to practice being smoke free.
“Stress Busters and Stretching” Group discussion and flip chart key benefits of stretching
• Ask if anyone in the group does a specific activity to reduce stress.
Introduce stretching as an easy way to reduce tension and stress.
• In order to alter stress you need to change something. By taking time for yourself you can withdraw from
a stressful situation, let go of tension in your body, clear your mind and take time for you.
• How can stretching help to reduce stress?
“Stretching Helps Your Body in a Variety of Ways” (Session 11: Handout) Review page two of “Stress
Busters and Stretching” (Session 10: Handout). Demonstrate a couple of stretches either sitting or standing
and ask the group to join you.
Homework: Practice stretching and deep breathing exercises.
Session 11
Being Active
pg. 2
regular meals.
reading a book.
Session 11
Being Active – Patient/Client Weekly Checklist
pg. 3
Session 11: Handout
Here are some suggestions for activities to get you moving:
• Get active for 10 minutes, 3 times a day, everyday.
• Get off the bus one or two stops early and walk the rest of the way.
• March in place during TV commercials.
• Park your car a block or two away and walk.
• Use the stairs instead of the elevator.
• Rake the leaves.
• Take a walk after dinner instead of watching TV.
• Moving any part of your body—even for a short time—can make you healthier.
• Walk the dog.
• Take 2-3 minute walking breaks throughout the day.
• Put away the TV remote control—get up to change the channel.
• Plan your errands around town so they are walking distance from each other (i.e. post office, library,
cleaners, pharmacy).
• Walk with a friend at lunchtime for 10 minutes.
• Walk to the store and home instead of driving.
• Dance to some of your favourite songs on the radio.
• Gardening.
• Clean a room.
Session 11
Handout
pg. 4
Session 11: Handout
50 Ways to Make Physical Activity Part of Your Life!
Play tennis
Go bowling with friends
Walk to work
Go rollerblading
Try skiing
Bike to school
Go ice skating
Go snowshoeing
Shovel snow
Play basketball
Play on a softball team
Try boxing
Go running
Go canoeing or kayaking
Play volleyball
Take a walk
Carry your groceries
Take a Pilates class
Join a garden club
Mow the yard with a push mower
Hike your local trails
Take up golf
Walk around the mall
Go camping
Play soccer
Jump rope
Walk the dog
Go dancing
Try skateboarding
Hit the beach
Take the stairs
Lift light weights during
TV commercials
Walk in the park
Train for a triathlon
Play catch
Wash the car by hand
Do jumping jacks during
TV commercials
Rearrange the living room
Rake the leaves
Throw a Frisbee
Park far away when getting groceries
Get off the bus 2 or 3 stops early
and walk the rest
Join a sport team
Play with the kids
Try karate
Go to a yoga class
Participate in municipal
recreation programs
Go sledding
Stretch in the morning or
during TV commercials
Session 11
Handout
5
50 Ways to Make Physical Activity Part of Yourpg.
Life!
Session 11: Handout
1. Increases Flexibility – Flexibility is the degree to which an individual muscle will lengthen.
Lack of flexibility causes movement to become slower and less fluid and makes you more susceptible
to muscle strains, ligament sprains, and other soft tissue injury.
2. Improves Circulation – Stretching increase blood flow to the muscles bringing more nourishment to
the muscle and removing more waste byproducts. Increased blood flow can also help speed up recovery
from muscle and joint injuries.
3. Improves Balance and Coordination – The increased flexibility that comes from stretching improves
balance and coordination. Improved balance and coordination lowers risks for falls.
4. Helps Alleviate Lower Back Pain – Stiff and tight muscles in the lower back, hamstrings, hips, and
buttocks is one of the more common causes of lower back pain. Stretching will alleviate the pain.
5. Helps Improve Cardiovascular Health – Stretching can improve artery function and lower
blood pressure.
Citation: Adapted from: www.functional-fitness-facts.com/benefits-of-stretching.html
Session 11
Handout
pg. 6
Tab Session 12
Session 12:
Healthy Eating
Nutrition.Intake.Maintain.Appetite
Healthy Eating
• Thoughts and/or feelings about the MAPP group finishing soon.
Review homework from last week. Ask group if they did any stretching exercises at home?
“Healthy Eating” Group discussion: In this session, we are going to talk about healthy eating and why it is
important to eat as healthy as we can on the budget we have.
• When you are having a craving for a cigarette, you may actually be hungry, or thirsty. You may feel light
headed, tired, lack energy, and have a headache. Because symptoms may be the same, it is important
to try drinking lots of water, have a snack, or eat a meal if you have skipped one. Try to eat regularly
throughout the day (at least every 4-6 hours).
• Too much caffeine can cause headaches, upset stomach and make a person nervous and jittery and
unable to sleep. Try reducing caffeine intake to 2 cups a day. Try a reduced caffeine or caffeine free drink.
Caffeine was mentioned in session 2; ask the group if anyone has tried reducing their caffeine?
• Meals can be easy and simple (i.e. a can of beans, an egg, a sandwich, baked potato).
• Snacks could include an apple or piece of fruit (canned or fresh), a handful of cereal, nuts, crackers and
cheese or peanut butter.
“Healthy Snacks for Adults” (Session 12: Handout)
http://www.dietitians.ca/getattachment/5e341ed5-7094-4e4b-bf04-a19307416cb0/FactSheet-Healthy-Snacksfor-Adults.pdf.aspx
• Smoking curbs the appetite, so some people notice once they stop smoking that they are hungry
more often. After 48-72 hours of stopping smoking, the sense of taste and smell improve and food
starts tasting better.
Ask the group what their experience has been with eating when they tried to stop smoking in the past. Some
people are concerned about weight gain when they stop smoking. If fear of weight gain is an issue, discuss the
following points: “Nutrition Tips When You Stop Smoking” and “Causes of Weight Gain and Strategies”
(Session 12: Handouts).
• Incorporating lots of activity and snacking can help deal with weight issues that people may have when
they stop smoking.
Session 12
Healthy Eating
pg. 1
If budget allows an “Oatmeal Buffet” refer to information sheet in resource sections for ingredients, directions
and discussion points (see Appendix A: Session 12: Resource).
“Canada’s Guidelines for Healthy Eating” (Session 12: Handout). Discuss key points
http://www.ymcahbb.ca/filemanager_files/Health%20Tips/Canada%20Guidelines.pdf
• Enjoy a variety of foods.
• Emphasize cereals, breads, other grain products, vegetables, and fruits.
• Choose lower fat dairy products, leaner meats, and foods prepared with little or no fat.
• Achieve and maintain a healthy weight by enjoying regular physical activity and health eating.
• Limit salt, alcohol and caffeine.
“Caffeine”. Review and discuss handouts “What is Caffeine? Is It Bad for My Health?” and
“Food Sources of Caffeine” (Session 12: Handout).
http://www.dietitians.ca/getattachment/63592edf-afb3-4ce9-a821-a95851a9e5c6/FactSheet---What-iscaffeine---Is-it-bad-for-my-health.pdf.aspx
http://www.dietitians.ca/getattachment/e412c60a-db49-4a91-bc6e-4f01ad46cbd6/Factsheet---Food-Sourcesof-Caffeine.pdf.aspx
• Caffeine occurs naturally in products such as coffee, tea, chocolate and cola type soft drinks and
are added to a variety of prescriptions and over the counter medications including cough, cold and
pain remedies.
• Energy drinks contain both naturally occurring and added caffeine.
• Caffeine is a stimulant that speeds up your central nervous system.
• The average amount of caffeine consumed per person in Canada is estimated to be approximately 2 cups
per day (210-238 mg).
“How Does Caffeine Make You Feel?”
• Caffeine stimulates the brain, elevates the mood and postpones fatigue.
• If you consume caffeine before bedtime, you will likely take longer to get to sleep, sleep for a shorter time
and sleep less deeply.
• Caffeine will not help you “sober up” if you’ve had too much alcohol. The caffeine will make you more
alert, but your coordination and concentrate will still be impaired.
• Too much caffeine can give you headaches, upset your stomach, make you nervous and jittery and leave
you unable to sleep.
• It can also cause flushed face, increased urination, muscle twitching and agitation. Some people feel these
effects after as little as 2 cups a day.
• It takes about four hours for half of a given dose of caffeine to be metabolized by the body.
Session 12
Healthy Eating
pg. 2
“Is Caffeine Dangerous?”
• Moderate amounts of caffeine, up to 400mg a day (3 average size cups 237 mg) will rarely harm an
otherwise healthy body.
• If you regularly drink more than 6-8 cups of coffee or your intake is higher than 600mg you may have
trouble sleeping and feel anxious and restless.
• Higher amounts can cause extreme agitation, tremors and very rapid irregular heartbeat.
• Combing high doses of caffeine with alcohol can be dangerous because caffeine can make you feel less
intoxicated, so you may continue to drink more or to behave in ways that are risky to you and others.
“What Can You Do?”
• Cut back on your caffeine consumption.
• Drink de-caffeinated or half caffeinated coffee.
• Switch to tea which has less caffeine.
• Replace several cups of coffee with water.
“Five Health Benefits of Clementines” Optional Discussion (Session 12: Handout).
• If in season, purchase and take a crate of clementines (or apples) to the class and talk about their benefits.
In addition to the nutritional benefits, peeling a clementine could keep your hands busy during a craving.
Resources: For patients/clients, who would like further information on healthy eating, refer them to the
Dietitians of Canada Website; www.dietitians.ca and those listed at the end of page 2 of the handout,
“Nutrition Tips When You Stop Smoking”. (Session 12: Handout).
Local Community Resources: Promote local Public Health nutritionists/dietitians, or grocery store dietitians
who host classes and tours that clients could access for more information.
Homework: Review the healthy eating handouts and pick one thing that you would like to work on for the
week i.e. reduce caffeine, eat breakfast, drink more water.
Session 12
Healthy Eating
pg. 3
regular meals.
reading a book.
Session 12
Healthy Eating – Patient/Client Weekly Checklist
pg. 4
Session 12: Handout
Healthy Snacking Can Be Part of Healthy Eating
Snacks are foods or drinks eaten between meals.
Healthy snacking, as part of a healthy diet, is a great
way to get all the nutrients you need. Nutrients help you
stay healthy and give you energy. Snacks can keep your
blood glucose (sugar) levels stable throughout the day.
This can help to curb your feeling of hunger between
meals and stop you from eating too much at mealtimes.
The keys to healthy snacking are:
 the foods you choose
 the amount you eat
 how often you snack


This fact sheet provides you with tips on choosing
healthy snacks and healthy portion sizes.
Steps You Can Take
 Plan healthy snacks by using "Eating Well with
Canada's Food Guide"
.www.healthcanada.gc.ca/foodguide. Try to
include foods from at least 2 of the 4 food
groups for each snack.
 Limit your snacks to no more than three a day.
Aim for snacks with less than 200 calories each
(see examples in the chart below).
 Keep a variety of healthy ready-to-eat snacks on
hand. Examples of healthy ready-to-eat snacks
are fruit with low fat yogurt, vegetables with



light dip or low fat cottage cheese, whole grain
crackers with hummus, peanut butter or low fat
cheese.
Watch your portion size. Buy small packages of
food or take small portions from larger
packages. Eat slowly. Don't snack directly from
a large container, bag or box.
Choose foods that are higher in calories, fat,
sugar, or salt (sodium) and lower in fibre less
often. These foods include cookies, cakes,
chocolates, ice cream, chips, and deep-fried
foods. If you can't resist eating these foods, try
to eat only a small amount. For example,
instead of eating two cookies, eat one cookie
and some fresh fruit. Or put a small scoop (golf
ball size) of ice cream in a small bowl and top it
with fresh or frozen fruits.
Drink water often. Water has no calories. Water
quenches your thirst and helps you feel full.
Learn to recognize true hunger and fullness.
Skip the urge to nibble when you are bored,
tired, upset or stressed. Try something else like
walking the dog, going for a jog, reading a
book, writing in a journal or listening to your
favourite music.
Avoid snacking while watching TV, working or
playing on the computer, reading, or driving
PAGE 1
Session 12
Handout
pg. 5
Session 12: Handout
Here are some healthy snack ideas for you:
Calories
Less than 100
Healthy Snack Ideas










Less than 200












1 medium fresh fruit (e.g. banana, pear, apple or orange).
250 mL (1 cup) fresh/frozen/canned cantaloupe, berries (e.g. cherries, blueberries,
strawberries, raspberries) or grapes.
1 large stalk of celery with ¼ cup low fat cottage cheese.
250 mL (1 cup) mixed green salad with 1 Tbsp low fat salad dressing.
125 mL (½ cup) low fat yogurt.
500 mL (2 cups) air-popped of low fat microwave popcorn.
3-4 arrowroot cookies, ginger snaps, or plain graham crackers.
Low salt pretzels (30 twists or 18 grams).
250 mL (1 cup) of mini carrots, cut up cucumbers, zucchinis, cherry tomatoes or other raw
vegetables.
2 Tbsp of nuts such as unsalted peanuts, almonds, hazelnuts, cashews or walnuts.
1 slice of whole grain/whole wheat bread or flat bread (e.g. Pita, Naan, or Roti) with 1 Tbsp of
hummus.
½ whole grain or whole wheat bagel with 1 Tbsp of peanut butter or nut butter.
250 mL (1 cup) fresh fruit low fat yogurt parfait. Layer vanilla yogurt with mandarin oranges
or berries. Sprinkle with granola.
7 whole grain crackers or 2 melba toasts with 33 grams (1 oz) of low fat cottage cheese or
light canned tuna.
250 mL (1 cup) fruit smoothie made with yogurt, soy or lowfat milk and a blend of your
favourite fruits.
1 English muffin with 1 Tbsp of melted low fat cheese and apple slices.
250 mL (1 cup) of plain milk or chocolate milk (skim, 1% M.F. or 2% M.F.).
250 mL (1 cup) of unsweetened applesauce.
A bag of homemade trail mix (60 mL or ¼ cup of mini shredded wheat, 2 Tbsp of dried
cranberries and 2 Tbsp of almonds or chopped walnuts).
1 small bran muffin.
Unsalted soy nuts 60 mL (¼ cup).
125 mL (½ cup) milk pudding.
PAGE 2 Session 12
Handout
pg. 6
Session 12: Handout
Tips on Reading Food Labels
Reading food labels tells you if a food is a healthy
choice. Look for a Nutrition Fact Table on packaged
foods and drinks. It will tell you the serving size and the
amount of some nutrients in each serving. It will list the
total fat, saturated fat, cholesterol, sodium and fibre.
The percent Daily Value (% DV) column in the Nutrition
Facts Table shows the amount of a nutrient in food
compared to the average amount of a nutrient
recommended each day. Choose foods with a lower %
DV of fat, saturated and trans fat, cholesterol, and
sodium. Choose foods with a higher % DV of fibre,
vitamins A and C, calcium and iron. To learn more about
how to read food labels, see the following links:
 Canadian Diabetes Association, Dietitians of
Canada. "Healthy Eating is in Store for You Nutrition Labelling Fact Sheets" .
www.healthyeatingisinstore.ca/pdf/ENG_BW_Fa

ctSheet.pdf.
Canadian Diabetes Association, Dietitians of
Canada. "Healthy Eating is in Store for You Frequently Asked Questions About Nutrient
Content Claims Healthy Eating is in Store for
You – Nutrition Labelling Fact Sheets"
.www.healthyeatingisinstore.ca/pdf/ENG_RGB_
FAQ.pdf.
Additional Resources
 "Eating Well with Canada's Food Guide" .
www.healthcanada.gc.ca/foodguide. For a free
guide, phone 1-800-622-6232.
 "Canada's Physical Activity Guide" .
www.paguide.com. For a free guide, phone 1888-334-9769.
 EATracker . www.eatracker.ca. Get personalized
feedback on your daily food and activity
choices.
 Dietitians of Canada .
www.dietitians.ca/eatwell. Find a variety of
interactive areas to help you assess your food
choices, plan menus and test your nutrition
knowledge.
These resources are provided as sources of additional
information believed to be reliable and accurate at the
time of publication and should not be considered an
endorsement of any information, service, product or
company.
PAGE 3 Session 12
Handout
pg. 7
Session 12: Handout
Nutrition Tips when you
STOP SMOKING
1. DO SOMETHING ELSE:
Smokers often connect certain situations with cigarettes.
When you quit, you may be tempted to eat in that situation.
For example, if you always had a cigarette with your coffee
or after a meal, you may have a strong craving for one at
these times. Change old habits.
• Don’t reach for the cookie jar or a coffee mug.
• Get up from the table as soon as you are done.
• Brush your teeth.
• Go for a walk.
• Try herbal tea, juice or another different drink that
may not be linked with cigarettes.
2.
3.
SATISFY THE URGE TO MUNCH WITH HEATLHY CHOICES:
Food will smell and taste better once you have stopped
smoking and you may not be tempted to eat more to cope
with nicotine cravings. That’s fine, as long as you…
• Build most meals and snacks around healthy foods like
whole grains, vegetables, fruits, lower fat dairy
products, leaner meats and meat alternatives.
• Avoid skipping meals – when you’re hungry, you may
be more likely to crave nicotine and to overeat later in
the day.
• Combine smaller servings at breakfast, lunch and
dinner with a variety of healthy lower fat snacks.
MISS THE FEEL OF HAVING SOMETHING IN YOUR MOUTH?
Make up a “nutrition survival kit” to help keep your mouth
busy. Keep a stock of crisp, crunchy or chewy items in your
home, at your work, in the car or anywhere else you usually
smoked. Here are some healthy ideas to start with:
• carrot sticks, celery sticks and other raw veggies
in bite size pieces
• oranges, melon slices, apples or other fresh fruits
• air-popped popcorn, rice cakes or pretzels
• bread sticks or bagel halves
• sugar-free gum or mints
• baked corn chips
Canadian Cancer Society
Smoker’s Helpline
www.smokershelpline.ca
4. DRINK LOTS OF FLUIDS:
Cold water helps to flush the nicotine out of your
system, and helps give your mouth something to do if
you get the urge to smoke.
•
•
•
Drink 6-8 glasses of water a day.
Fruit juices, clear soups and low fat milk (skim or 1%)
are healthy ways to add more fluid to your diet.
Avoid or reduce alcohol. It may trigger a cigarette
craving, especially if you used to drink and smoke at
the same time.
4. EXERCISE REGULARLY:
Regular exercise will help curb your appetite, burn calories,
relive stress and increase your sense of well-being. So…
• Be Active!
• Take the Stairs.
• Walk, cross-country ski, swim, or dance.
• Choose the activities you enjoy and stick with them.
5. REWARD YOURSELF FOR NOT SMOKING:
Don’t use food as the grand prize!
• Put your “cigarette money” aside and spend it on a
special item of clothing, entertainment or reward.
• Spoil yourself by saving up for a big ticket item, like a
holiday.
• Celebrate each non-smoking anniversary; the first day,
week, month and year.
6. GET OTHERS TO HELP YOU:
• Ask your family and friends for support.
• Be direct. Tell them you would like options such as
healthy snacks at get-togethers.
• Ex-smokers may be particularly reassuring, so ask for
their advice.
• Contact your local Tobacco Control Coordinators: they
can link you with local resources.
Contact your Public Health Nutritionist
Hours:
Phone Toll Free and Confidential
1-877-513-5333
Fridays 9am – 7pm
Session 12
Handout
pg. 15
Nutrition Tips When You STOP SMOKING
Session 12: Handout
SMOKING:
IF YOU QUIT, YOU DON’T
HAVE TO GAIN WEIGHT!
“Sure I’d love to quit smoking, but I’m really afraid of gaining
weight.”
“If I quit smoking and gain weight, haven’t I just traded one
health problem for another?”
Today, many people are giving up smoking. Many more would like
to quit but are afraid of gaining weight.
No, you haven’t. Consider this. The health hazards from smoking
one pack-a-day are equal to the problems you can have carrying an
extra 125 pounds (57 kilos) more than what your height and build
can normally handle.
Some people do gain weight when they quit smoking, but not
everyone does.
Studies have shown that while two-thirds of people who quit gain
weight, one-third stay the same, and some even lose.
For those who do gain, the average is usually 4 to 13 pounds
(2 to 6 kilos).
“Is it possible to gain weight when you quit, even if you don’t
eat more?”
Yes, it is possible. The research suggests that smoking changes
metabolic processes (how you burn calories).
Remember, the average weight gain after you quit smoking is only 4
to 13 pounds (2 to 6 kilos).
“Can I eat whatever I want until I’ve kicked the smoking habit?”
No, it’s too easy to get caught in a vicious cycle. Some people who
quit start eating large amounts and their weight goes up. Then the
weight gain is used as an excuse to start smoking again.
When they return to their old eating (and smoking) habits, they will
lose weight. They may feel smoking is an effective weight control
program. It isn’t.
This might explain why smokers tend to weigh less than nonsmokers.
Once you quit, your metabolism may slow down – meaning you
won’t need as much food as when you were smoking.
A regular cardiovascular-based exercise program such as swimming,
cross-country skiing or brisk walking is recommended to keep your
metabolism up.
USEFUL RESOURCES
Dietitians of Canada – www.dietitians.ca
Fruits and Vegetables – www.5to10aday.com
The Canadian Health Network – www.canadian-health-network.ca
Health Canada – www.gosmokefree.ca
NS Office of Health Promotion, Tobacco Control – www.gov.ns.ca/health/tcu or www.sickofsmoke.com
Smokers’ Helpline – 1-877-513-5333
Hours:
Fridays 9am – 7pm
Produced by Public Health Services.
May be reproduced provided source is acknowledged.
Session 12
Handout
pg. 16
Smoking: If You Quit, You Don’t Have to Gain Weight!
Session 12: Handout
Problem/Cause
Solution/Strategy
You need to put
something in your mouth.
Before snacking, make sure you are hungry. If you really need to eat,
try low calorie snacks.
You feel stressed.
Try relaxation techniques (breathing) or gentle stretching; brief, brisk
walks; drinking lots of water; and eating low-calorie snacks. Eat slowly
in a calm, relaxed atmosphere. Chew food more thoroughly.
You crave high-calorie food.
Keep your stomach full with lots of water and eat more raw
vegetables.
You crave sweets.
Eat fresh, crunchy fruits, sour foods, pickles, or cooked sweet
vegetables (carrots, squash, etc).
You are hungry all the time.
Eat foods high in nutrients. Follow Canada’s Food Guide. If still hungry,
drink more water and eat more raw fruits, vegetables, and low-fat
dairy products.
You can’t taste anything.
Eat fresh fruits and vegetables, and wholegrain breads and cereals.
Eat less sauce, butter and gravy. Use herbs and spices to bring
out flavours.
You want “treats”.
Give yourself non-food rewards. Sleep in, buy something special with
your cigarette money, spoil yourself.
Your metabolism is slow.
Increase physical activity. Keep moving: walk, bike, dance, swim, play
and sports. Choose activities you enjoy and stick to them.
Session 12
Handout
pg. 10
Session 12: Handout
Healthy eating is as easy as following these five points.
X
This is the best way to ensure you are eating
well. Your body needs over 50 nutrients a day.
No one food will provide all of them. The sure
way to get all the nutrients you need is to mix
and match different foods daily. Vitamin and
mineral supplements cannot make up for poor
eating habits. Besides, eating is much more
enjoyable than taking a pill.
Broccoli is very nutritious, but you don’t have to
eat it every day. Don’t forget carrots,
cauliflower, dark leafy greens, winter and
summer squashes, green and red peppers,
snow peas, red cabbage, sweet potatoes ...
you get the picture! The list of vegetables
available for your enjoyment is endless. Frozen
mixed vegetables make it easy to get an
assortment at a single meal. And, frozen
vegetables are just as nutritious as fresh!
Remember, it is the total diet, not individual
Reach for three or more servings of
Enjoy a VARIETY of foods.
foods that influences health.
Y
Emphasize cereals, breads, other
grain products, vegetables and
fruits.
Eating well means planning your meals around
foods from the earth - grains, vegetables, and
fruit - the backbone of a healthy diet. Meals
built around these foods are a feast of textures,
colours, flavours, and aromas. These foods
provide complex carbohydrates and are
naturally low in fat.
Diets high in complex carbohydrates have
been associated with a lower risk of heart
disease and some cancers. Also, whole grain
products, vegetables, and fruit add dietary
fibre, which may help you manage your weight
because they fill you up before you eat too
many calories.
Go beyond bread, rice, and pasta - try
couscous, quinoa, bulgur, barley, kasha,
and wild rice for variety. Once available
only in health food stores, most of these
grains have become supermarket regulars.
vegetables per day. A serving is probably
smaller than you think; a half-cup of cooked
or fresh vegetables equals one serving!
While a glass of fruit juice at breakfast is a great
start, how about some bananas, peaches, or
dried fruit on top of your cereal or waffles? A
crisp apple or juicy orange makes a great
midday snack. A bowl of ripe, red strawberries
topped with low fat vanilla yogurt for dessert is a
tasty way to end a meal.
Reach for two or more servings of fruit per
day. A half-cup of juice or fruit equals one
serving – easy!
Z
Choose lower-fat dairy products,
leaner meats and foods prepared
with little or no fat.
Eating less fat provides short and long term
health benefits. By cutting back on fat, you
may reduce the amount of saturated fat and
cholesterol in your diet.
Choose milk, yogurt, and other dairy
products that are 1% milk fat (M.F.) or less.
Look for cheese that is skimmed, partskimmed, or less than 20% M.F.
Session 12
Handout
pg. 8
Session 12: Handout
Think of the size and thickness of a deck of
\
Low fat cooking methods include broiling,
Most of the salt in our diet comes from
processed foods. Choose lower salt versions of
these foods more often. Try to include more
meals and snacks that you make from scratch
so you can control the amount of salt used.=== ====== =
cards as a healthy portion size of meat, fish,
or poultry.
steaming, roasting, baking, microwaving,
grilling, braising, boiling, poaching, and stir
frying (if a small amount of oil is used).
Marinades without oil tenderize lean meats
as well as those with oil. Acidic ingredients,
like citrus juice, vinegar, or wine, do the
tenderizing. Try a fat free salad dressing for
a quick, twenty minute marinade.
Lower fat foods may have fewer calories
than higher fat ones, but check the labels to
compare. Some low fat foods, like cookies
or muffins, have just as many calories as the
original version because of the increased
sugar added to the product.
[
Achieve and maintain a healthy
weight by enjoying regular
physical activity and healthy
eating.
Limit salt, alcohol and caffeine.
Use less salt when cooking. Add herbs and
spices to enhance the natural flavours of
foods.
Remove the salt shaker from the table.
Limit highly salted chips, pretzels, nuts, and
crackers.
Although there is a lot of news in the media
about alcohol possibly reducing the risk of heart
disease, the other side of the story is rarely told.
Alcohol can also increase the risk of liver
disease, suicide, injuries, and several cancers,
including breast cancer. To improve your
health, eat better, exercise more, and don’t
smoke rather than drinking more or starting to
drink! If you choose to drink alcohol, follow this
advice:
People who have lost weight and kept it off
have done it through regular physical activity
and sensible eating. Forget about trying drastic,
low calorie or fad diets and ignoring physical
activity. An active lifestyle can greatly improve
how you look and feel. Remember that healthy
bodies come in many shapes and sizes, so keep
your healthy weight goal realistic.
Have no more than one or two drinks on any
Healthy eating means eating a variety of foods
to meet your nutrient and caloric needs. If you
restrict your food intake too much, chances are
you will not meet your nutritional needs, and
you will probably feel like you’re denying
yourself.
Enjoying that morning cup of coffee is a
common practice, and that’s OK. Just keep in
mind how much and how often you reach for
coffee and other caffeine-containing
beverages throughout the day.
Strike a balance between eating well and
moving your body daily!
day.
To help have the healthiest baby possible
don’t drink if you might become pregnant,
are pregnant or are breastfeeding. No safe
level of alcohol consumption during these
times has been identified.
If you have more than 400 - 450 mg of caffeine
per day (about four 6-ounce cups of coffee),
you may want try some other beverages. Enjoy
decaffeinated coffee or tea, herbal teas,
coffee substitutes, fruit juice, or low fat milk for a
change. Don’t forget that cola drinks and
chocolate also contain caffeine.
Produced and distributed by the City of Hamilton Public Health and Community Services Department.
For more information please call the Nutrition and Physical Activity Advice Line at 905-546-3630 or
visit www.hamilton.ca/phcs
October 2002
Session 12
Handout
pg. 9
Session 12: Handout
What is caffeine? Is it
bad for my health?
Where is caffeine found?
Caffeine is found naturally in over 60 plants such as
coffee and cocoa beans, tea leaves, kola nut, yerba
mate, and guarana. It's also used in soft drinks, energy
drinks and drugs such as some cold and pain remedies.
Coffee and tea are the main sources of caffeine for
adults, while soft drinks are the main sources for
children.
How does caffeine affect my health?
It's well-known that caffeine makes us more alert and
delays sleep. It's also popular among athletes, since it
can improve performance in some sports.
People often wonder whether caffeine is safe.
•
•
Right now, it appears that a moderate caffeine intake
does not increase the risk of developing cardiovascular
disease, osteoporosis or cancer.
Contrary to popular opinion, caffeinated drinks do not
dehydrate us, especially if we are used to caffeine.
How much caffeine is safe?
Many different foods, beverages and medicines contain
varying amounts of caffeine.
•
•
Health Canada recommends that adults limit their
caffeine intake to no more than 400-450 mg/day. This is
about the amount found in three 8-ounce cups of regular
coffee.
Health Canada also recommends that pregnant and
breastfeeding women limit their intake to no more than
•
300 mg per day (2 cups of coffee or 6 cups of tea).
Caffeine can be passed to an infant in breast milk, which
may result in irritability and sleeplessness.
Recommended limits for children are even lower (45
mg/day for children 4-6 years, 62.5 mg/d for 7-9 years
and 85 mg/day for children 10-12 years). It doesn’t take
much for children to reach these limits; a 12-oz can of
cola contains about 45 mg of caffeine, an energy drink
has about 80 mg and a solid milk chocolate bar has
contains about 10 mg.
For the average healthy adult, moderate caffeine intakes
pose no health risk, especially if we eat a balanced diet
and enjoy regular physical activity.
Trying to cut back?
Many people who are used to having caffeine
experience side effects like headaches and drowsiness
when they suddenly stop taking it. Here are some tips to
cut back slowly:
•
•
•
•
•
Mix your regular coffee with half decaffeinated coffee.
Try caffeine-free herbal teas or apple cider for a hot drink.
Choose a latte or café-au-lait over brewed coffee.
Brew tea for less time.
Try caffeine-free versions of your favourite carbonated
beverages.
Important Warning – Health Canada warns us to never
mix caffeine with ephedrine (ma huang) due to potential
serious health risks.
PAGE 1
Session 12
Handout
pg. 12
What is Caffeine? Is It Bad for My Health?
Session 12: Handout
Food Sources
of Caffeine
Information about Caffeine
 Caffeine is a chemical that is found naturally in
the leaves and seeds of various plants. Natural
sources of caffeine include coffee beans, cocoa
beans, kola nuts, tea leaves, yerba mate and
guarana.
 Caffeine can be added to energy drinks and
some carbonated drinks and drug products.
 Caffeine excites the central nervous system. It
also improves alertness for short periods of
time.
 Some people are more sensitive to caffeine
than others. For these people too much caffeine
can cause:
•
•
•
•
•
•

trouble sleeping
anxiety
irritability
nervousness
rapid heart rate
headaches.
People who often include caffeine in their diet
may experience side effects such as headaches
or drowsiness if they suddenly stop having it.
Caffeine Intake
The following amounts of caffeine are considered safe
Age in Years
Stay below milligrams (mg)/day
Men and Women 19 and older
Pregnant and Breastfeeding women 19 and older
400
300
Food Sources of Caffeine*
Food
Serving Size
Caffeine (mg)
Coffee, brewed
250mL (1 cup or 8 oz)
80-180
Coffee, instant
76 – 106
Espresso, brewed
30 mL (1 oz)
64-90
Cappuccino or Latte
45-75
Coffee or coffee based beverages
UNTIL MAY 2015
1
Session 12
Handout
pg. 13
Session 12: Handout
Decaffeinated coffee
3 – 15
Coffee liqueur
45 mL (1½ oz)
4-14
Coffee, instant, decaffeinated
3-5
Decaffeinated espresso
30 mL (1 oz)
0
Iced Tea, sweetened
1 can (341-355 mL)
15-67
Tea, leaf or bag (black, flavoured black)
250mL (1 cup)
43-60
Tea (green, oolong, white)
250mL (1 cup)
25-45
Decaffeinated tea
250mL (1 cup)
0-5
Herbal ‘teas', all varieties
250mL (1 cup)
0
Energy drink, various types
250mL (1cup)
80-125
Diet cola
355 mL (1 can)
25-43
Cola
355 mL (1 can)
30
Dr. Pepper (regular, diet)
355 mL (1 can)
40
Barq’s Root Beer**
355 mL (1 can)
23
Chocolate covered coffee beans, dark or milk chocolate
60 mL (1/4 cup)
338-355
Chocolate, dark
1 bar (40 g)
27
Hot chocolate
250 mL (1 cup)
5-12
Milk chocolate bar
1 bar (40 g)
8-12
Chocolate brownie
1 brownie (24-34 g)
1-4
Chocolate milk
250mL (1 cup)
3-5
Yogurt, chocolate
175 g (3/4 cup)
4
Chocolate pudding
125mL (1/2 cup)
2
Ice cream, chocolate
125mL (1/2 cup)
2
Tea
Soft Drinks and Energy Drinks
Cocoa Products
* The caffeine content in foods can vary a lot
**Certain brands of root beer do not contain caffeine
Source: "Canadian Nutrient File 2010" .
http://www.hc-sc.gc.ca/fn-an/nutrition/fiche-nutri-data/index-eng.php
[Accessed May 16, 2012]
UNTIL MAY 2015
2
Session 12
Handout
pg. 14
Session 12: Handout
Find out how these festive oranges, only 35 calories each,
can help you fight off illness and relieve the effects of the holiday stress.
Clementines are a cross between an orange and mandarin and
they first became popular in the 1980’s when a deep freeze in Florida
made oranges scarce. They have only 35 calories each and are one of
the easiest varieties of citrus to peel, making them a great choice
for a snack on the go.
When the hustle and indulgence of the holiday season is getting to you, peel a clementine and breathe in
deeply – the essential oil in the peel has a calming effect and is used in aromatherapy to relieve anxiety and
fight depression. What’s more, rubbing the peel on your skin may help allergic skin rashes.
Here are five more reasons to pick up a box of clementines on your next shopping trip:
1. Clementines are a source of vitamin C: Vitamin C helps prevent upper respiratory tract infections,
along with the common cold and flu. Stock up on clementines during this flu season to help prevent
infection. When you are stressed over the holidays you use more vitamin C, so enjoy a minimum of two
clementines a day to get healthy intake.
2. They’re great for dental health: Clementines are a source of potassium, and getting enough dietary
potassium decreases dental inflammation, reduces hypertension, and prevents tooth loss.
3. Protect your liver with clementines: Clementines contain choline, a B vitamin that aids in healthy liver
function. We stress our liver during all the holiday parties this season. People with a deficiency of choline
in their diet are more prone to developing non-alcoholic fatty liver disease and steatohepatitis.
4. Clementines are a source of folate: Folate (or folic acid) is a part of the B vitamin family. Recent studies
have found that folate is necessary in the brain for the regulation of mood. If you find the holidays
stressful, clementines are a stress buster. Folate is often used in conjunction with other therapies to aid
in the treatment of depression specifically in women.
5. Clementine oil is a potent antioxidant: The oil extracted from the peel of clementines and other citrus
fruits, has been shown to be a powerful antioxidant and pain reliever (antinociceptive). Include a bit of
the peel in your smoothies to reap these benefits.
Session 12
Handout
pg. 11
Session 13:
Tab Session 13
Coping With
Pressures to Smoke
Reduce.Consequence.Control.Alternative
Coping With Pressures to Smoke
• How did the plan for physical activity go this past week?
• How did the trying healthy foods go this past week?
Review Homework from last week. Review the healthy eating handouts and pick one thing that you would
like to work on for the week, i.e. reduce caffeine, eat breakfast, and drink more water.
“Coping With the Pressures to Smoke (The 3 A’s)” (Session 13: Handout) Group discussion: Flip chart and
review handout with group.
Avoid It – remove yourself from the stressful/tempting situation. Walk away, or avoid making contact in the
first place.
Alter It – change the situation; take control. Ask they are pressuring you to smoke. Explain your feeling say
“No Thanks”, repeat until you sound like a broken record.
Accept It – if you can change the situation, or take control, build up your strength to resist.
• Ask the group if they have had experience in using the 3 A’s.
• Which one is the hardest to use?
“Steps to Cope With the People, Places and Things That Tempt Me to Smoke” (Session 13: Handout)
Group discussion.
Session 13
pg. 1
“Saying NO to Cigarettes” (Session 13: Handout) Group discussion:
• Have two facilitators role play a situation where one has to say NO.
• The situation should be one facilitator trying to get the other facilitator to go out (for coffee, fast food,
dessert, and bar) and do something or have something they have stopped doing.
• Go over “Cigarette Refusal Skills” (Session 13: Handout):
ūū
ūū
ūū
ūū
ūū
SAY “NO THANKS”
DIRECT EYE CONTACT & WATCH BODY LANGUAGE, BE FIRM
CHANGE THE SUBJECT
SUGGEST ALTERNATIVES
CONFRONT THE AGGRESSOR, REMEMBER IT’S YOUR RIGHT TO NOT SMOKE
• Pair off the group members and have them do the role play where one person tries to tempt the other
to have a cigarette. If the group is not comfortable with role playing, facilitators can role play and ask the
group to give suggestions to help the person who is being treated.
• Have a group discussion about the results.
• Discuss the benefits of not smoking vs. the consequences of starting smoking again.
Review the questions on page 2 of “Saying NO to Cigarettes.” (Session 13: Handout).
• Is it possible for me to have just one cigarette?
• Do I really want this cigarette enough to give up everything I have been working on?
• Can I wait for 7 minutes and see if the craving/urge passes?
Homework: “Setting Up a Support Team” and “Cigarette Refusal Skills” and “Say No Thanks!”
(Session 13: Handout).
Patients/clients may have had some changes or additions to support them, in their journey to stop smoking,
since supports were discussed at the beginning of the program.
Session 13
pg. 2
regular meals.
reading a book.
Session 13
Coping With Pressures to Smoke – Patient/Client Weekly Checklist
pg. 3
Session 13: Handout
Coping With the Pressures to Smoke (The 3 A’s)
AVOID It
Remove yourself from stressful situations.
Walk away, or avoid making contact in the first place.
ALTER It
Change the situation. Take control. Ask why they are pressuring you to smoke.
Explain your feelings – say “No Thanks” – repeat until you sound like a broken record.
ACCEPT It
If you can’t change the situation, or take control, build up your strength to resist.
Session 13
Handout
4
Coping With the Pressures to Smoke (The 3pg.
A’s)
Session 13: Handout
Step 1:
Don’t blame yourself or others.
Step 2:
Describe the problem:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Step 3:
Talk about it: “I feel…
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Step 4:
Brainstorm with myself and others, all the ways the problem might be solved.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Step 5:
Choose one of those ways and try it. Plan the how, when and where.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Step 6:
After I’ve tried it, I’ll think about if it worked or not. If it didn’t help, I’ll try something else.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 13
Handout
pg. 5
Session 13: Handout
The most common reasons that people go back to smoking after stopping is:
• They saw another smoker.
• They were offered a cigarette by someone who smokes.
Therefore, it’s a good idea to plan ‘how’ to say no when this happens (and it will happen eventually!)
Practice in this group or in front of a mirror what you would say if someone offered you a cigarette.
Examples:
• ‘No thanks Dan, I don’t smoke anymore’.
• ‘Thanks for offering Dan, but I stopped smoking and don’t want to smoke ever again’.
• ‘No thank you Dan, I’m a non-smoker now’.
Besides practicing by yourself, you can practice role-play situations in this group. You can practice how to say
no to cigarettes and practice other high-risk situations that make you want to smoke. To assist in learning how
to refuse cigarettes, use these five steps in refusal skills:
•
•
•
•
•
Ask questions
Recognize when you’re in trouble
Think about the consequences
Suggest other activities
Get out of there
Ask yourself these questions:
• Is it really possible for me to have just one cigarette?
• Do I really want this cigarette enough to give up everything I have been working on?
• Can I wait for 7 minutes and see if the craving/urge passes?
Recognize when you’re in trouble.
One cigarette will probably lead to more!
I always end up smoking when I am:
List a place: ____________________________________
List a person: ___________________________________
Think about the consequences.
I will start coughing again if I smoke.
I will start spending $ ______ per week on cigarettes if I start smoking again.
I have enjoyed using that money I have saved on:
___________________________________________________________________________________________
Session 13
Handout
pg. 6
Session 13: Handout
It is not easy to stop smoking.
Most people who try, have had help
at one time or another. A good support team
can help you reach your goals. Think about the
people you have in your life, where you live,
work, socialize, and receive treatment.
Write the names of the people you would
like to have on your support team.
Coaches…
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Team Mates…
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
Cheering Section…
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
By-Standers…
___________________________________________
___________________________________________
___________________________________________
___________________________________________
___________________________________________
A coach might be a group home leader or health care worker with knowledge about stopping smoking.
A team mate might be another smoke Cessation group member or a friend in your life trying to stop smoking.
Your family, friends or health care worker might be your cheering section or they might be by-standers who
will be less involved but available to help you reach your goals.
Session 13
Handout
pg. 9
Session 13: Handout
When you are urged to smoke, keep the following in mind:
1. Say “NO THANKS”, first in a clear, firm and unhesitating voice.
2. Make direct eye contact, and watch your body language.
3. Change the subject.
4. Suggest alternatives: Something else to do or something else to eat or drink.
5. Ask the person to stop offering you a cigarette, and not to do so again.
6. Avoid using excuses or vague answers.
7. Remember: It’s your right not to smoke!
Session 13
Handout
10
Cigarette Refusalpg.
Skills
Session 13: Handout
Cigarette Refusal Skills (con’t)
When you are urged to smoke, keep the following in mind:
1. Say “NO THANKS”, first in a clear, firm and unhesitating voice.
2. Make direct eye contact, and watch your body language.
3. Change the subject.
4. Suggest alternatives: Something else to do or something else to eat or drink.
5. Ask the person to stop offering you a cigarette, and not to do so again.
6. Avoid using excuses or vague answers.
7. Remember: It’s your right not to smoke!
Practice Exercise
Who are some people in your life who you could imagine offering you a cigarette in the future?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What are some things you can say if people offer you cigarettes?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 13
Handout
pg. 7
Session 13: Handout
Say No Thanks!
Who are some people in your life who you could imagine offering you a cigarette in the future?
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
What are some things you can say if people offer you cigarettes?
1.__________________________________________________________________________________________
2.__________________________________________________________________________________________
3.__________________________________________________________________________________________
Session 13
Handout
pg. 8
Say No Thanks!
Tab Session 14
Session 14:
Slips and Relapse
Reflect.Evaluate.Ack nowledge.Journey
Slips and Relapse
Review homework from last week. “Setting Up a Support Group” and “Cigarette Refusal Skills Practice
Exercise” and “Say No Thanks!” (Session 13: Handout).
• Stress the importance of being prepared. You may be tempted. Have your support ready.
• Check in about how group members feel about completing the program.
• Check in with group members about the goals and expectations of the group and individual members.
(Reflect on the beginning weeks of the MAPP program compared to the completion).
“Dealing With Setbacks” (Session 14: Handout) Group discussion:
• Remember your previous attempts as practice for the day you stop for good.
• Should we blame ourselves for a slip? What should we do?
• If you use tobacco again, should you be hard on yourself? It takes courage to stop smoking.
You have the skills and supports to start again.
• Does one slip mean you have failed?
• If you have a slip why is it important to get back on track immediately?
“Slip or Relapse” (Session 14: Handout) Group discussion.
“Role Play With the Chair” Group discussion:
• Set a chair in the centre of the room and tell the patients/clients the chair represents a person that would
like to stop smoking.
• Ask the patients/clients to describe the MAPP group and what would help to start the process to stop
and/or reduce their smoking.
• To inform about benefits vs. consequences.
• To inform about the difference between addiction and habits.
• To inform about what withdrawal to expect and that withdrawal may feel similar to their mental
health conditions.
• Emotions and moods around withdrawal and dealing with cravings and/or triggers.
Session 14
Slips and Relapse
pg. 1
• Stress management.
• The importance of planning and preparation.
• Skills, change in thinking, and follow-up.
• Nutrition, rest and physical activity.
• Dealing with peer pressures.
• Dealing with slips and/or relapse.
• What things the group members thought worked in the MAPP program and what could be improved.
Supports – remind group of their supports for the coming weeks, (mental health worker, smokers’ helpline
and online support, Addiction Services, family, friends). These people are their ongoing supporters in
staying smoke-free.
You may want to skip break and add time for patients/clients to talk at the end of the session.
“Ending the Group” (see Appendix A: Session 14: Resource). It is important to have a group closing with the
patients/clients as they have shared this remarkable journey together. Celebrating all of the successes of the
group is key, even though some may not have met their goal of stopping smoking. For those patients/clients
that have reduced their tobacco use, it is a positive life change, and requires positive acknowledgement.
Some of the patients/clients have made new friends within the group and who will continue to be supportive
of each other and this must be celebrated as well.
“Overall Program Evaluation” (see Appendix C: Session 14: Form)
“MAPP Group Closing and Certificate Presentation” (see Appendix C: Session 14: Form)
Reading if using river stones or beach stones:
• Those River Stones broke off a mountain near an ocean shore or river’s edge millions of years ago.
The water and waves tumbled these rough stones for a million years before they became smooth and
formed this unique shape. The rocks themselves are over 200 million years old.
• The River Stones represent your personal journey (process) of growth you have shown in the completion
of this MAPP program. The River Stone is a reminder of your perseverance and your determination to have
healthier life and to continue to set and achieve your goals and dreams.
Session 14
Slips and Relapse
pg. 2
regular meals.
reading a book.
Session 14
Slips and Relapse – Patient/Client Weekly Checklist
pg. 3
Session 14: Handout
Dealing With Setbacks
You may have been unsuccessful in your last stop attempt. Maybe even in your last few stop attempts. When
this happens, it is common to feel disappointed or feel like you have failed. This feeling may have discouraged
you from trying again.
Remember that research has shown that most smokers try to stop a number of times before they are able to
stop for good.
• Try thinking of your previous attempts as practice for the day you will stop forever.
• Instead of blaming yourself, think about all that you have learned from each attempt that will be helpful
to you now.
• If you use tobacco again, don’t be too hard on yourself. Forgive yourself and remember it takes courage to
stop smoking.
• One slip does not mean that you are a failure or that you cannot be a nonsmoker.
• If you slip, it is important to get yourself on the nonsmoking track immediately. Review your triggers and
coping skills, and try again.
IMPORTANT POINT TO REMEMBER: Research has shown that most smokers try to stop a number of times
before they are able to stop for good.
Revised June 2005.
Session 14
Handout
pg. 4
Dealing with Setbacks
Session 14: Handout
Slip or Relapse
What if you do smoke? The difference between a slip and a relapse is within your control. When you have a slip,
it means that you had a cigarette without thinking things through. You have a choice at this point! You can use
the slip as an excuse to go back to smoking, or you can look at what went wrong and renew your commitment
to staying off smoking for good.
What reasons stopped you from achieving your goals?
Physical Addiction/Withdrawal symptoms
• Remember that withdrawal symptoms are most severe within the first 1 to 3 days of abstinence, and
can often continue for several weeks. The physical symptoms of withdrawal, while annoying, are not life
threatening. Nicotine replacement or medications can help reduce many of these physical symptoms.
• In addition, if these symptoms were severe and caused you to smoke, you could be successful in future
stopping if you used more or different medications.
Psychological Addiction
• If you have been using tobacco for any length of time, it has become linked with many of your activities
– watching TV; attending sport events; while fishing, camping, or driving your car. It will take time to
“un-link” smoking from these activities. That is why, even if you are using medications, you may still have
strong urges to smoke.
If these psychological reasons caused you to smoke, you could be successful in future stopping if you used
more or different support and counselling treatment.
IMPORTANT TIP TO REMEMBER: If you have recently tried to stop and slipped up or started smoking again,
just get right back on track – you haven’t lost any time and will probably be more successful this time if you
learn from your mistakes in the past!
Session 14
Handout
pg. 5
Slip or Relapse
Session 14: Handout
Slip or Relapse (con’t)
Remember the reasons you wanted to stop smoking.
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Where are the places that you should avoid to stay smoke-free?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
What are some habits you can change that could make a difference while trying to stop?
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Session 14
Handout
pg. 6
Slip or Relapse
Tab Appendix A - Resources
Appendix A:
Resources
Nurture.Progress.Educate.Evolve
Resource: Session 1
Did You Know…
• Tobacco kills three times more Canadians than alcohol, AIDS, illicit drugs, car accidents, suicide and
murder combined. (Tobacco Control Unit, Government of Nova Scotia)
• Tobacco use is the leading cause of preventable illness, disability and premature death in Canada. (Health
Canada, 2012)
• Smoking prevalence among those with mental illness and addiction is significantly higher than the
general population; ranging from 40% to 90% depending on the co-occurring diagnosis and setting of
study. (2012 CAN ADAPTT Canadian Smoking Cessation Guideline)
• Smokers with other addictions and mental health illness are more likely to die of tobacco related causes
than from diseases associated with other drug and alcohol addiction or mental health illness. (Colton CW,
Manderscheid RW. 2006)
• Smoking is usually the first addictive substance used and smoking may increase the likelihood of using
other substances such as illicit drugs and alcohol. (Baca, Yahne, 2008)
• Smoking causes brain damage including harm to auditory verbal learning and memory, general
intellectual abilities, balance and the brain’s motivational systems but may take years to impact brain
function significantly. Cigarette smoking doubles the risk of dementia and Alzheimer’s disease. (Gons, et
al. 2011)
Tobacco and Addiction: Common Myths
Nicotine addiction is not addressed with individuals having illicit drug and alcohol addictions because:
• Smoking cessation treatment will negatively impact the primary addiction treatment.
• People in treatment do not want to quit smoking.
• Mentally ill clients do not want to stop smoking (2012 CAN ADAPTT Canadian Smoking Cessation Guideline).
The Facts
• Smoking reduces alcohol’s effects, likely encouraging more drinking. (Carmody, et al. 2012)
• Smoking cessation interventions result in effective drug and alcohol treatment outcomes, including
reducing the risk of relapse and increasing long term sobriety. (Prochaska JJ, 2012)
• Research shows people do want to quit and advice from doctors and structured interventions from
nurses are effective. (2012 CAN ADAPTT Canadian Smoking Cessation Guideline)
Adapted from: Addiction and Prevention Treatment Services, Capital Health, Nova Scotia
Resource: Session 1
pg. 1
Tobacco and Mental Health: The Facts
• Among patients with mental health and addictive disorders, smoking prevalence seems to be highest
among those with a diagnosis of schizophrenia and substance use disorders with prevalence rates of
70 – 90%. (Disease Interrupted; Editors: Els, Kunyk & Selby, 2012)
• Lifetime smoking prevalence among people with psychiatric disorders (55.3%) and substance use
disorders 72.2%) were significantly higher compared with the general population (39.1%). (Disease
Interrupted; Editors: Els, Kunyk & Selby, 2012)
• People with schizophrenia who smoke experience increased psychiatric symptoms, need for higher
medication doses and increased number of hospitalizations. (Williams et al 2004; Williams, Foulds, 2007)
• Research suggests that smoking and depression share the same neurobiological substrates. (2012 CAN
ADAPTT Canadian Smoking Cessation Guideline, Disease Interrupted; Editors: Els, Kunyk & Selby, 2012)
• Smoking cessation interventions may benefit those with mental illness, but heightened surveillance
and proper assessment by a team of professionals is necessary. (2012 CAN ADAPTT Canadian Smoking
Cessation Guideline; George et al. 2008)
• Given that persons with mental illness are at risk for multiple adverse behavioural and health outcomes,
tobacco cessation will have substantial benefits, including a reduction in excess morbidity and mortality
attributed to tobacco use. (http://www.cdc.gov/mmwr, 2012)
Nicotine an Addictive Substance
• Nicotine dependence is classed as a tobacco use disorder under the psychoactive substance use
disorders. (www.who.int/tobacco 2012)
• Nicotine is psychoactive and causes observable behavioural effects, such as mood changes, stress
reduction and performance enhancement. (Disease Interrupted; Editors: Els, Kunyk & Selby, 2012)
• The behavioural effects associated with nicotine delivered during smoking include arousal, increased
attention and concentration, enhancement of memory and reduction or anxiety and suppression of
appetite. (Disease Interrupted; Editors: Els, Kunyk & Selby, 2012)
• Nicotine produces close-related psychoactive effects in humans that are similar to those of stimulants.
(Disease Interrupted; Editors: Els, Kunyk & Selby, 2012).
What Can We Do?
• Educate health professionals about the harms of nicotine addiction. (2012 CAN ADAPTT Canadian
Smoking Cessation Guideline)
• Provide advice to the patient about nicotine addiction from physicians and other health professionals as it
is proven to be effective. (2012 CAN ADAPTT Canadian Smoking Cessation Guideline)
• Incorporate smoking cessation programs in all mental health, addictions programs e.g. outpatient and
residential programs. (2012 CAN ADAPTT Canadian Smoking Cessation Guideline)
• Eliminate smoking in all addiction and mental health programs. (Williams et al. 2004)
Citation: Adapted from Addiction and Prevention Treatment Services, Capital Health, Nova Scotia
Resource: Session 1
pg. 2
Resource: Session 1
Top 10 Myths About Tobacco Cessation in the Mentally Ill
Common Myth
Comments Based on the Scientific Evidence
1. “There are more important things
than smoking cessation in the
mental healthcare.”
Tobacco use is the leading preventable cause of death and disease in
the mentally ill, with a 50% mortality rate, vastly surpassing suicide as
a cause of death.
2. “People with mental illness cannot
quit smoking, nor do they want
to quit.”
They are indeed interested in quitting and, with the right levels of
support and intervention they can succeed, similar to non-mentally
ill smokers.
3. “Quitting smoking will lead to
relapse to mental illness.”
With sufficient support, quitting smoking is not associated with a
relapse to mental illness. However, untreated and forced involuntary
abstinence from tobacco may increase the potential risks for harm.
4. “Varenicline is causally related to
suicide and should be avoided in
the mentally ill.”
Untreated smoking cessation can lead to changes in mood, abnormal
dreams, aggression, suidicality, irritability, plus behaviour and
appetite changes. No causal relationship has been established
between the use of medications for smoking cessation and suicide.
5. “Facilitating access to tobacco for
patients with mental illness helps
to improve their quality of life.”
Facilitation to access to tobacco leads to higher levels of
consumption and increased difficulty in accepting
smoking-cessation interventions.
6. “If the mentally ill do not have
access to tobacco, they cannot
be controlled and will become
aggressive, increasing the risk
of violence.”
With appropriate support levels, there is no evidence to suggest
increased levels of violence, patients leaving hospitals against
medical advice, increased use of physical or chemical restraints,
or risk of violence to healthcare providers.
7. “Expecting the mentally ill to
quit smoking violates their
human rights.”
There is no constitutional right to smoke, and healthcare providers
are ethically obligated to routinely offer evidence-based treatments
to smokers.
8. “Mentally ill persons will smoke
while on the nicotine patch,
which will lead to heart attacks.”
There is no excess cardiovascular risk associated with
co-administration of pharmaceutical nicotine while using
tobacco-derived nicotine (smoking).
9. “Medications (eg. Nicotine
replacement, varenicline,
bupropion) may only be used
for periods not exceeding
2-3 months.”
Medications can be safely and effectively used for longer periods,
if clinically indicated. Cautiously exceeding the on-label indications
for duration of some treatments appears to provide additional
benefits in terms of outcomes.
10. “Tobacco-cessation treatment
is not effective.”
In the domain of mortality prevention, smoking-cessation
interventions have a number needed to treat value of 9, indicating a
substantial level of clinical meaningfulness. It is considered at least as
treatable as most other chronic diseases.
Citation: Adapted from Charl Els, MBChB, FCPsych, MMedPsych, Cert. ASAM, MROCC, and Diane Kunyk, RN, MN, PhD (Student), CIHR
Strategic Training Fellow
Resource: Session 1
pg.Ill
3
Top 10 Myths About Tobacco Cessation in the Mentally
Resource: Session 1
Overview People living with mental illness are more likely to smoke and be at greater risk for smoking‐related health problems than the general population.1 Smoking can affect the brain and body just like other drugs. Smoking also affects the way medications work. It’s important for patients who take medications for mental health problems to talk with their health care providers about how much they smoke and to let them know if they stop smoking. Smoking and Mental Illness • People who live with a psychiatric disorder or a substance use disorder are 2‐4 times more likely to smoke than the general population. 1 Up to 88% of people with schizophrenia 2 and 83% of people with bipolar disorder smoke. 3 • Smoking affects the way some anti‐psychotic and anti‐depressant medications are broken down by the body. People who smoke heavily may need higher doses of medication than those who do not smoke. 2,4,5
• People who take medications for their illness need to work closely with health care providers when they reduce or stop smoking altogether because they may need to adjust doses of their medications in order to prevent toxicity or side effects. 2,6,9 • Smoking can provide relief from some of the symptoms of attention hyperactivity disorder, depression, schizophrenia and the side effects of some anti‐psychotic medications, but smoking has not been proven as an effective adjunctive therapy for such disorders. Smoking has been shown to increase risk of more serious health problems, including the deterioration of both physical and mental health status. 2,4,5‐8 • People who quit smoking may improve their health almost immediately and save money on medications. 2
• Patients living with mental health and/or substance use disorders who smoke can get help by talking with a health care provider no matter their stage of change. • Patients living with mental health and/or substance use disorders are able to quit smoking with support. They can benefit from evidence‐based smoking cessation medications and behaviour counselling approaches. 9, 10,11
Helpful Resources • The CAMH (Center for Addiction and Mental Health) Nicotine Dependence Service www.camh.net • Smokers’ Helpline www.smokershelpline.ca (1 877 513‐5333) • Tobacco Treatment for Persons with Substance Use Disorders http://smokingcessationleadership.ucsf.edu/Downloads/Steppsudtoolkit.pdf
Resource: Session 1
pg. 4
Resource: Session 1
References 1. Kalman, D., Morissette, S., George, T. (2005). Co‐Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders. The American Journal on Addictions, 14,106–123. 2. Els, E., Kunyk., D., McColl, L. (2009). Benefits and Risks of Smoking Cessation: The Fundamental Importance of Cessation Must be Recognized. Smoking Cessation Rounds, 3(4) Retrieved May 9, 2011 from <http://www.smokingcessationrounds.ca/crus/140‐025%20English.pdf> 3. Lasser, K., et al. (2000, Nov.). Smoking and Mental Illness: A Population‐Based Prevalence Study. The Journal of the American Medical Association, 284 (20), 2606‐ 2610. 4. Action on Smoking and Health. (2011, Feb.). Smoking and Mental Health. ASH Fact Sheets. Retrieved June 29, 2011 from <http://www.ash.org.uk/files/documents/ASH_120.pdf> 5. Faculty of Public Health. (2008).Mental Health and smoking: A Position Statement. London: Faculty of Public Health. 2008. Retrieved June 20, 2011 from <http://www.fph.org.uk/uploads/ps_mental_health_and_smoking.pdf> 6. McNeil, Ann. (2004). Smoking and patients with mental health problems. London: Health Development Agency. Retrieved June 20,2011 from < http://www.nice.org.uk/niceMedia/documents/smoking_mentalhealth.pdf> 7. CAN‐ ADAPTT. (2010, Dec. 7). Canadian Smoking Cessation Guideline. Specific Populations: Mental Health and Addiction. Retrieved May 9, 2011 from <http://www.can‐adaptt.net/> 8. Lawn, S., et al. (2002). Smoking and Quitting: A Qualitative Study with Community‐Living Psychiatric Clients. Social Science & Medicine, 54, 93–104. 9. Kaduri, Pamela. (2011, March 29) Mental Health and/or Other Addictions. CAN‐ADAPTT Webinar Series. Toronto: Centre for Addiction and Mental Health. 10. Prochaska, Judith. (2011, July 21). Smoking and Mental Illness—Breaking the Link. The New England Journal of Medicine, 365;3 11. Banham, L. & Glibody, S. (2010). Smoking cessation in severe mental illness: What works?.Addiction, 105(7):1176‐89. Selby P et.al, CAN-ADAPTT Guide to Smoking Cessation. www.canadaptt.net
Resource: Session 1
pg. 5
Resource: Session 1
Overview People living with mental illness are more likely to smoke and be at greater risk for smoking‐related health problems than the general population. Smoking and tobacco interact with some psychiatric medications and therefore, people being treated for mental illnesses require clinical supervision when they quit or reduce smoking in order to address possible side effects and medication toxicity. The Link between Smoking and Mental Illness • Research has shown that people who have been diagnosed with a psychiatric disorder or a substance use disorder are 2‐4 times more likely to smoke than those in the general population. 1 Up to 88% of people with schizophrenia 2 and 82.5 % of people with bipolar disorder smoke.3 • People living with mental illness or substance use disorders consume 44.3% of all cigarettes sold in the U.S., although they represent only 22% of the population. 3 • Nicotine and inhaling smoke can alleviate some of the symptoms of attention hyperactivity disorder and may counteract depression. 4 Nicotine has been found to alleviate some of the symptoms of schizophrenia and may provide relief from side effects of antipsychotic medications. 2,4,5,6 People living with mental health disorders may use cigarettes as a coping mechanism, although the risks of smoking greatly outweigh the benefits. 2, 7, 8 Impact • People living with mental illness are more likely to smoke greater numbers of cigarettes, and be more heavily addicted and therefore at greater risk for smoking‐related health problems than the general population. 2 • If patients reduce or stop smoking, their medications need to be carefully monitored to prevent side effects and toxicity. 2,5, 6 • Smoking cessation can reduce the doses and costs of psychiatric medications needed. 7 • Patients with mental health and/or substance use addictions who quit smoking may need higher doses of pharmacological aids like Nicotine Replacement Therapy than non‐smokers. 9 Actions • Although smoking rates among people with mental health disorders are disproportionately high, existing anti‐
smoking campaigns are rarely directed to this population.6 Smoking cessation strategies could significantly improve their physical health–an aspect of care that is often overlooked. 6,7 • Health care providers should ask about tobacco use in the same way that they would ask about any other drug. 6 Early identification of daily stressors is essential for the prevention of dependence on cigarettes for social, physical, and psychological comfort. 8 • Although people living with mental illnesses are more likely to smoke, there is evidence that they are also able to quit, particularly if they are supported with a combination of pharmacotherapy and counselling. 3, 10 It is important to monitor the interaction of medications and the impact of smoking cessation on medication doses, toxicity and side effects. 2, 5,11,12 Appendix A - Resources
Resource: Session 1
pg. 6
Resource: Session 1
Actions • The CAN‐ADAPTT Guideline Development Group12 recommends that health care providers should: – Ask patients about tobacco use status on a regular basis. – Clearly advise patients or clients to quit. – Assess the willingness of patients or clients to begin treatment to quit smoking. – Offer assistance to every tobacco user who expresses the willingness to begin treatment to quit. – Conduct regular follow‐up to assess response, provide support and modify treatment as necessary. – Refer patients or clients to relevant resources as part of the treatment, where appropriate. Helpful Resources • The CAMH (Center for Addiction and Mental Health) Nicotine Dependence Service <www.camh.net> • Smokers’ Helpline <www.smokershelpline.ca> • Tobacco Treatment for Persons with Substance Use Disorders <http://smokingcessationleadership.ucsf.edu/Downloads/Steppsudtoolkit.pdf> References 1.
Kalman, D., Morissette, S., George, T. (2005). Co‐Morbidity of Smoking in Patients with Psychiatric and Substance Use Disorders. The American Journal on Addictions, 14,106–123. Els, E., Kunyk., D., McColl, L. (2009). Benefits and Risks of Smoking Cessation: The Fundamental Importance of Cessation Must be Recognized. Smoking Cessation Rounds, 3(4) Retrieved May 9, 2011 from <http://www.smokingcessationrounds.ca/crus/140‐025%20English.pdf> Lasser, K., et al. (2000, Nov.). Smoking and Mental Illness: A Population‐Based Prevalence Study. The Journal of the American Medical Association, 284 (20), 2606‐ 2610. McNeil, Ann. (2004). Smoking and patients with mental health problems. London: Health Development Agency. Retrieved June 20,2011 from < http://www.nice.org.uk/niceMedia/documents/smoking_mentalhealth.pdf> Action on Smoking and Health. (2011, Feb.). Smoking and Mental Health. ASH Fact Sheets. Retrieved June 29, 2011 from <http://www.ash.org.uk/files/documents/ASH_120.pdf> CAN ADAPT T. (2010, Dec. 7). Canadian Smoking Cessation Guideline. Specific Populations: Mental Health and Addiction. Retrieved May 9, 2011 from < http://www.can‐adaptt.net/> Faculty of Public Health. (2008).Mental Health and smoking: A Position Statement. London: Faculty of Public Health. 2008. Retrieved June 20, 2011 from <http://www.fph.org.uk/uploads/ps_mental_health_and_smoking.pdf> Lawn, S., et al. (2002). Smoking and Quitting: A Qualitative Study with Community‐Living Psychiatric Clients. Social Science & Medicine, 54, 93–104. Prochaska, J, et al. (2008, Mar.) Treating Tobacco Dependence in Clinically Depressed Smokers: Effect of Smoking Cessation on Mental Health Functioning. American Journal of Public Health, (98) 3, 446 ‐448. 2.
3.
4.
5.
6.
7.
8.
9.
10. Campion, J., Checinski, K. & Nurse, J.(2008). Review of smoking cessation treatments for people with mental illness. Advances in Psychiatric Treatment, 14, 208‐216. 11. Kaduri, Pamela. (2011, March 29) Mental Health and/or Other Addictions. CAN‐ADAPTT Webinar Series. Toronto: Centre for Addiction and Mental Health. CAN‐ADAPTT. 12. CAN_ADAPTT. (January 2011). Canadian Practice‐Informed Smoking Cessation Guideline: Summary Statement. Toronto: The Canadian Action Network for the Advancement, Dissemination and Adoption of Practice‐informed Tobacco Treatment, Centre for Addiction and Mental Health. Retrieved June 27, 2011 from <http://www.can‐
adaptt.net/English/Guideline/Counselling%20and%20Psychosocial%20Approaches/Summary%20Statements.aspx> Selby P et.al, CAN-ADAPTT Guide to Smoking Cessation. www.canadaptt.net
Resource: Session 1
pg. 7
Resource: Session 1
Assessment of carbon dioxide levels in smokers is a direct measure of a consequence of smoking cigarettes.
• Carbon monoxide (CO) is a product of combustion of tobacco.
• Smokers can have 2-20% of their normal blood oxygen taken up by CO.
• This lack of oxygen increases the risk of damage to the heart muscles, can affect your ability to
concentrate and can make you tired.
• It is detrimental to health both in the short-term and long-term because it displaces oxygen in the
red blood cells.
• Under-oxygenated blood places strain on the heart and is a risk factor for cardiovascular disease.
• The heart has to work harder to deliver adequate tissue nurturing oxygen throughout the body.
This puts the smoker at greater risk for heart attacks.
Measurement of carbon monoxide is a potentially powerful biofeedback technique for individuals engaged
in tobacco use reduction and smoking cessation. Stopping smoking results in levels of carbon monoxide
dropping back to normal levels within 2 to 3 days. Carbon monoxide:
• can be measured using a carbon monoxide meter.
• is measured by a meter, is portable and easy to use.
• measures carbon monoxide in parts per million [ppm].
• allows for initial assessment documentation of expired carbon monoxide [CO] for individuals entering
into smoking cessation programs.
• measurement can be easily repeated over the course of participation in treatment programs during a
planned tobacco use cessation; and, will readily demonstrate the return to normal of carbon monoxide
levels. This both confirms abstinence and motivates the individual to continue to be smoke-free.
Overall carbon monoxide measurement is an efficient tool for both education and motivation. MAPP clients
repeatedly reported valuing this personal biofeedback information during the course of their own tobacco
cessation journey. This tool can become a powerful part of group check-in: providing immediate sign of
physical health gains and clear indication of the reduced use and /or non-use of tobacco and/or exposure
to secondhand smoke. The group could celebrate individual gains and motivate each other to make further
changes in their smoking behaviour as they begin to understand that their CO level will quickly go down to
safe levels by stopping smoking.
Patients are often curious and concerned about their assessment results. Respond positively to any curiosity
expressed, since this is a sign of treatment engagement.
Resource: Session 1
pg. 8
Resource: Session 2
In recent history, cigarette companies have been forbidden to use the words ‘light’ or ‘mild’ on cigarette
packages. The tobacco companies made these cigarettes so that consumers would assume ‘light’ or ‘mild’ are
not as harmful. In fact, all conventional brands including the ‘light’ and ‘mild’ brands present the same level of
risk to people who smoke.
Now current research shows that people who smoke base their perceptions of risk on colour. For example,
consumers believe that ‘silver’ or ‘gold’ brands are less harmful than ‘black’ or ‘red’ brands. It is believed that the
reason for these beliefs is in the history of cigarette branding such as the ‘light’ or ‘mild’ cigarettes that have
been recently banned in Canada. However, since the manufacturers are no longer allowed to use words like
‘mild’ or ‘light’; they have substituted those words with ‘gold’ or ‘silver’ which again misleads the consumer to
believe that these ‘colour’ cigarettes are low-risk as well.
‘Smooth’ is simply again a marketing term cigarette manufacturers use to mean the smoke is not harsh. It has
no ‘real’ meaning.
Studies have shown that adults and youth were significantly more likely to rate packs with the terms ‘smooth’,
‘silver’, ‘gold’ as lower tar, lower health risk and either easier to stop smoking (adults) or their choice of pack
if trying smoking (youth). It is apparent that the health benefits from ‘silver’, ‘gold’ and ‘smooth’ cigarettes are
illusory – they are no less harmful that ‘regular’ cigarettes.
These ‘silver’, ‘gold’ and ‘smooth’ cigarettes are just natural successors of the former ‘light’ cigarettes claiming it’s
the perfect light smoking experience; both of which are key marketing strategies of the tobacco company.
Source: Adapted from Non-Smokers rights Association: http://www.nsra-adnf.ca/
http://www.sciencedaily.com/releases/2011/04/110412065802.htm
http://www.eurekalert.org/pub_releases/2011-04/w-sb041111.php
Resource: Session 2
pg. 9
Resource: Session 3
Contraband – The Facts
It’s a Crisis
Contraband tobacco is a serious problem in Canada that is getting worse each day. It is cheap, easily bought,
and lacks any government taxation, inspection or control.
Youth Facts
Kids have easy access.
Youth are smoking contraband cigarettes in alarming numbers. Cheap prices, easy access and no age-checks
means youth, who shouldn’t be smoking at all, are having no trouble getting tobacco through the contraband
market.
Criminals are selling contraband tobacco to teens and the proof is all over the school yard.
In 2007, 2008 and 2009 the Canadian Convenience Stores Association conducted a major study into the
proliferation of contraband tobacco at high schools in Ontario and Quebec. Over 100 sites were surveyed
and the results were staggering. Nearly one-third of the cigarettes found at Ontario high schools and over 40
percent of those found at Quebec high schools were contraband products.
The study conducted its research by visiting schools after hours and collecting discarded cigarette butts from
around school property.
Organized Crime Facts
Organized crime groups use the lucrative trade in contraband tobacco to finance other, more serious, criminal
activities. Contraband tobacco smuggling is often accompanied by drugs and guns.
Contraband tobacco is funding criminal organizations with links to other illegal activity such as firearms
and drug smuggling. As of 2011, the RCMP has identified over 175 organized crime groups involved in the
trafficking of contraband tobacco.
Lab analysis shows that insect eggs, dead flies, mold, even human feces have appeared in contraband
cigarettes.
Resource: Session 3
10
Contraband – Thepg.
Facts
Resource: Session 3
Contraband – The Facts (con’t)
Small Business Facts
Contraband cigarettes are killing small businesses and threatening the livelihoods of thousands of convenience
store owners. These contraband cigarettes, which are being smuggled throughout Canada in record numbers,
now represent one out of every three cigarettes purchased.
With smugglers offering tobacco prices as low as $8 per carton versus nearly $90 for legal cigarettes, legitimate
retailers are being forced to compete in an unfair playing field. This means individual stores are losing tens of
thousands of dollars in sales every year.
You are not in this fight alone. Together our members have worked to build this national coalition of people
and businesses all dedicated to fighting this growing problem. And we need your help fighting on behalf
of Canadians.
Government Tax Loss Facts
These are cigarettes that are being illegally imported from places like China or illegally sold, tens of thousands
of cartons each day, right here in Canada. This all happens with absolutely no government inspection, testing,
oversight or taxation.
Canada is being flooded with untested, unregulated and untaxed cigarettes.
CTV’s investigative news program, W5, reported in 2011 that contraband tobacco is robbing government of as
much as $2 billion in taxes every year.
Resource: Session 3
11
Contraband – Thepg.
Facts
Resource: Session 4
NRT/Pharmacotherapy Average Costs
(March, 2013)
Average prices, rounded off to the nearest dollar.
Nicotine Gum
2 mg 4 mg $12.00 for 30 pieces = .40 per gum
$31.00 for 107 pieces = .29 per gum
Nicotine Lozenge
2 mg
4 mg
$12.00 for 22 pieces = .55 per piece
$25.00 for 105 pieces = .24 per piece
Nicotine Patch
(all steps) $20.00 for 7 patches
= 2.86 per patch per day
Nicotine Inhaler
4 mg $36.00 for 42 count = .86 per inhalation
Nicotine Spray
1 mg $45.00 for 105 sprays = .43 per spray
Resource: Session 4
12
NRT/Pharmacotherapy Averagepg.
Costs
Resource: Session 4
What is an e-cigarette?
An electronic cigarette, or e-cigarette, is a cylindrical device made of stainless steel or plastic that mimics a
cigarette in terms of its appearance and use and sometimes taste, but with a critical distinction—it does not
contain tobacco.
E-cigarettes produce a vapour that resembles smoke and a glow that resembles the tip of a cigarette.
They consist of a battery-powered delivery system that vapourizes and delivers a liquid chemical mixture
that may be composed of various amounts of nicotine, propylene glycol, and other chemicals.
These products come as electronic cigarettes, cigars, cigarillos and pipes, as well as cartridges of nicotine
and non-nicotine solutions and related products.
What are the ingredients of e-cigarettes?
E-cigarettes produced in Canada can contain different ingredients than those produced in the US.
Ingredients can include: tobacco extract, synthetic peanut flavouring, food flavouring, propylene glycol
and vegetable glycerin. The inhalation of propylene glycol is a known irritant.
Where are e-cigarettes made?
E-cigarettes first arrived from China, and a large number are still manufactured there. Others are made in
various countries including Canada.
Are e-cigarettes safe to use?
Health Canada is advising Canadians not to purchase or use electronic smoking products, as these products
may pose health risks and have not been fully evaluated for safety, quality and efficacy by Health Canada.
Are e-cigarettes legal?
No, these products fall within the scope of the Food and Drugs Act, and under the Act, require market
authorization before they can be imported, advertised or sold. The sale of these health products is currently
not compliant with the Food and Drugs Act since no electronic smoking products have been granted a market
authorization in Canada.
Where are e-cigarettes sold?
E-cigarettes are available for sale with and without nicotine in a variety of locations including pharmacies,
barbershops, discount stores, gas stations, mall kiosks and on the Internet.
Do all e-cigarettes contain nicotine?
No, some are nicotine-free. However some products have been found to contain nicotine even though it is not
mentioned on the product. Those that contain nicotine have been found to contain amounts inconsistent with
the amounts shown on the product.
Resource: Session 4
pg. 13
Resource: Session 4
Questions & Answers – E-cigarettes (con’t)
Have e-cigarettes been tested?
E-cigarettes have not been adequately tested. There has been no high quality, scientific research
conducted that includes clinical trials, large study samples, over a reasonable amount of time.
Do e-cigarettes help people stop smoking?
No research exists to show the benefit of e-cigarettes for those wanting to stop smoking, so it has not
been determined if they are effective in helping people those stop smoking. E-cigarettes are not a
smoking cessation tool.
Proven Smoking Cessation Products include Nicotine Replacement Products (NRT) such as
nicotine patch, nicotine gum, nicotine lozenge, nicotine inhaler, nicotine spray, and pharmacotherapy
(i.e. Bupropion, Varenicline).
What are the concerns about e-cigarettes?
The rates for tobacco use have decreased considerably due to reduced social acceptability.
De-normalizing smoking has taken place due to legislation, regulated sales, ban on advertising
and adding graphic health warnings on packaging.
E-cigarettes are used like cigarettes and people are using them in public places. Advertising and sales
are not regulated. They are sold in a variety of places, including those where children are present.
This could re-normalize smoking.
How could youth be affected?
There is a concern that youth could try e-cigarettes and transition into smoking cigarettes. E-cigarettes are sold
in a variety of places and can be viewed as novelty gadgets with perceived low risk. Therefore e-cigarettes may
be attractive to youth and may lead to nicotine addiction and subsequent tobacco use.
How could people who smoke be affected?
Some people use e-cigarettes in places where they can’t smoke and then continue to smoke at home or
outside. E-cigarettes are not helping these people to stop; they are helping them continue with the addiction.
How can people who want to stop smoking be affected?
E-cigarettes are being shelved with proven NRT/cessation products. This can mislead the public into
thinking they have been researched like NRTs. People may choose to purchase them thinking they can
help them stop smoking.
How are E-cigarettes harmful to children?
E-cigarettes are harmful to children, given the risk of choking or nicotine poisoning.
Citations:
(2009) Health Canada Advisory. Health Canada Advises Canadians Not to Use Electronic Cigarettes
Non Smoker’s Rights Association, E-Cigarettes, http://www.nsra-adnf.ca/cms/page2292.cfm (retrieved January 30, 2013)
January 28, 2013 CBC Radio interview Melody Tilson, Policy Director, Non-Smokers Rights Association, Dr. Preet Rai, medical director of Smoke NV
Resource: Session 4
pg. 14
Resource: Session 4
Selby P et.al, CAN-ADAPTT Guide to Smoking Cessation. www.canadaptt.net
Additional references used to develop this algorithm are listed on page 2.
Resource: Session 4
pg. 15
Resource: Session 4
Algorithm for Tailoring Pharmacotherapy in Primary Care Settings (con’t)
Reduce to Quit
Glossary
BID: Twice a day
COPD: Chronic obstructive
pulmonary disease
d: Days
lbs: Pounds
LU: Limited use
NRT: Nicotine
replacement therapy
MAOI: Monoamine
oxidase inhibitor
Max: Maximum
ODB: Ontario drug benefit
OTC: No prescription
needed
PO: By mouth
PRN: As needed
qam: Every morning
Rx: Requires a prescription
SR: Slow release
Wt: Weight
Step 1: (0-6 weeks) Smoker sets a target for no. of cigarettes
per day to cut down (at least 50% recommended) and a date
to achieve it by. Smoker uses gum to manage cravings.
Step 2: (6 weeks up to 6 months) Smoker continues to cut
down cigarettes using gum. Goal should be complete stop by
6 months. Smoker should seek advice from HCP if smoking
has not stopped within 9 months.
Step 3: (within 9 months) Smoker stops all cigarettes and
continues to use gum to relieve cravings
Step 4: (within 12 months) Smoker cuts down the amount of
gum used, then stops gum use completely (within 3 months
of stopping smoking).
References
Information provided is evidence-based but may not be
approved for use in certain regions. Refer to your local
regulatory authority for approved indication, guidelines, and
updated safety information.
1. Bader P, McDonald P, Selby P. An algorithm for tailoring
pharmacotherapy for smoking cessation: results from a
Delphi panel of international experts. Tobacco Control. 2009
Feb;18(1):34-42.
2. Clinical Practice Guideline Treating Tobacco Use and
Dependence 2008 Update Panel, Liaisons, and Staff. A clinical
practice guideline for treating tobacco use and dependence:
2008 update. A U.S. Public Health Service report. Am J Prev
Med. 2008 Aug;35(2):158-76.
3. Gray, J, editor. Therapeutic Choices. 6th ed. Ottawa;
Canadian Pharmacists Association, 2011. Chapter 10:p. 15367. Chapter 10: 153-167
4. CAN-ADAPTT. Canadian Smoking Cessation Clinical
Practice Guideline. Toronto: Canadian Action Network for
the Advancement, Dissemination and Adoption of Practiceinformed Tobacco Treatment, Centre for Addiction and Mental
Health; 2011.
5. CAN-ADAPTT. Canadian Smoking Cessation Clinical Practice
Guideline: Pharmacotherapy section. Toronto: Canadian
Action Network for the Advancement, Dissemination and
Adoption of Practice-informed Tobacco Treatment, Centre for
Addiction and Mental Health; 2012.
Selby P et.al, CAN-ADAPTT Guide to Smoking Cessation. www.canadaptt.net
Resource: Session 4
pg. 16
Resource: Session 6
Self-Help Kit
Suggested Items:
• Juice Box
• Bottled Water
• Cards
• Gum – Sugar Free
• Toothbrush
• Notebook/Pencil
• Stress Ball
• Word Search
• Timer
• Window Cling
• Bubbles
• Piggy Bank
• Mental Health Kit
• Elastic – Stretch yourself to new limits
• Marble – So no one can ever say you’ve lost all your marbles
• Penny – So you’ll never be broke
• String – To tie things together when it feels like they are falling apart
• Eraser – To erase mistakes
Resource: Session 6
pg. Kit
17
Self-Help
Resource: Session 7
Picture yourself walking on a beach.
It’s early evening, and the sun is about to set.
You look at the sun (a big red ball in the sky).
The sky is clear, with patches of red and orange like a painting.
A few seagulls fly overhead, you watch them fly peacefully.
You walk along the beach, barefoot.
The sand feels warm on your feet.
You hear the rhythmic sound of the waves, faithfully coming in to meet the sandy shore.
You listen to the smoothing sound of the waves, lapping on the shore.
You walk along the beach, content to be looking, listening, and seeing the beauty of the sky and the ocean.
In the near distance you see a large piece of driftwood.
You walk up to it and find a place to sit on it.
You face the ocean and the sunset.
The sun is beginning to set.
You see it lowering, behind the water that seems to stretch out forever.
The sky is glowing now.
As you look at the sky in its beauty, you feel peaceful, healthy, whole, and content.
You remember today’s discussion, the people here, their faces, what you said, and what they said.
You have come this far with meeting people who share your journey, telling pieces of your story.
You tell yourself you will be a non-smoker.
Maybe not today, maybe not tomorrow, but in the future, you know you will be a non-smoker.
You rest content in the knowledge of your choices, and your decisions.
As the sun sets, you commend yourself for your efforts…
Resource: Session 7
pg. 18
DELAY
DELAY
DON’T FORGET
DON’T FORGET
DRINK WATER
DEEP BREATHE
DRINK WATER
DEEP BREATHE
DO SOMETHING ELSE
DO SOMETHING ELSE
DELAY
DON’T FORGET
DRINK WATER
DEEP BREATHE
DO SOMETHING ELSE
DELAY
DELAY
DON’T FORGET
DON’T FORGET
DRINK WATER
DEEP BREATHE
DO SOMETHING ELSE
DRINK WATER
DEEP BREATHE
DO SOMETHING ELSE
Resource: Session 7
pg. D’s
19
Four
DELAY
DON’T FORGET
DRINK WATER
DEEP BREATHE
DO SOMETHING ELSE
Resource: Session 7
pg. D’s
20
Four
Resource: Session 8
• We need to use our imaginations for the exercise.
• Everyone is asked to close their eyes, remain quiet and listen carefully.
• This is only a 2 minute exercise.
“Imagine you are in your kitchen. You are all alone, and it is quiet. Walk over to the fridge and open it up;
the only thing inside the fridge is a basket of lemons. Pick up the basket of lemons and place it on the counter.
You reach out and select a ripe yellow lemon. You feel the weight of the lemon in your hands…you slide your
fingers over the smooth waxy skin…feel the dimpled texture… you lift the lemon to your face and breathe
in that lemony smell…you go to the drawer and get a sharp knife and then you slice the lemon open. As the
bright yellow flesh is exposed you see the juice run out…a lovely citrus aroma fills the room. You cut a slice and
slowly put it in your mouth. You bite down on it…the juice runs over your tongue…your mouth fills with the
taste of lemon juice…”
• Discuss their experience with the exercise.
• Most people will find their mouthwatering after this visualization exercise.
• In order to make sense of what you hear or read your brain has to retrieve the memories, the images,
smells, textures the lemon visualization brings to mind.
• The experience of eating a lemon is something that generates powerful physical reactions.
• The experiences are similar to the powerful physical reactions that occur when ingesting drugs (nicotine).
• Recalling eating the lemon recalls the unique reaction, and your body responds with a conditioned reflex.
• The lemon guided imagery demonstrates that our thoughts and feelings undoubtedly do have a physical
effect on the body.
• It is important to remember this when you are having a bad craving…one that is so bad you think you can
taste the cigarette or feel like you are going to crawl out of your skin if you do not have a cigarette.
• How can cravings be bought on?
Resource: Session 8
pg. 21
Resource: Session 8
Sample Responses for “Pressures to Smoke and What to Do?”
“Smoking is my only pleasure” sample responses:
• There are other things I am going to enjoy with the money I will save.
• There are other things to enjoy.
• Feeling better will be a better pleasure.
• My family is proud of me, that’s a pleasure.
“I have nothing better to do” sample responses:
• I can go for a walk.
• I will drink some water.
• I can read.
• I will do some deep breathing exercises.
• I will call a friend or relative.
“Cigarettes are part of my life and I will panic without them” sample responses:
• I want to be a non-smoker for life.
• I can handle it; I plan to _____ when I feel panic.
• I know who I can call for support.
• I know I’ll feel better when I am in control and the cigarettes are not.
“All my friends smoke” sample responses:
• I am my own person; I don’t have to be like my friends.
• I can spend more time with my family.
• I will spend time with my friends in places where there isn’t any smoking.
• I am responsible for me and I want to be a non-smoker.
“I have to smoke to cope with the stress in my life” sample responses:
• I plan to walk the dog to get fresh air and reduce my stress.
• I plan to keep a diary of my stress by not expecting so much of myself.
• I will take some time to relax and reward myself.
“I’ve tried before and failed, it’s too hard to stop” sample responses:
• I know what I can do differently this time.
• I have a plan now and I know I will be smoke free this time.
• I have people to support me.
• This time, I will.
Resource: Session 8
22
Sample Responses for “Pressures to Smoke and What topg.
Do?”
Resource: Session 11
Overview Smoking and physical activity are 2 of the top 3 risk factors for early death and chronic disease that people can change. The Link between Smoking and Physical Activity • Young adults who are physically active are less likely to smoke and more likely to avoid smoking as adults. 2 • People who are physically active have less desire to smoke, 3 fewer cravings for tobacco and fewer withdrawal symptoms if they stop smoking. 2, 4 Physical activity can help people to quit smoking when exercise is combined with nicotine replacement therapy (NRT) such as a nicotine patch, gum or inhaler 5
and exercise delays weight gain in women who quit smoking. 6 • People who are not physically active may be more depressed, which may cause them to smoke or smoke more often.1 • Exercise can improve feelings of depression, anxiety, psychosocial stress, sleep patterns, cognitive functioning, and self‐esteem, which can help people to stop smoking and stay smoke free. 6 • A small increase in physical activity can significantly reduce the risk of developing a chronic disease. 8 • Participating in physical activity can help people to quit smoking and remain smoke‐free. Exercise also has many other important health benefits. 2, 4, 5, 9 • Exercise may be an alternative for some people who are unable or unwilling to take nicotine replacement therapy (NRT). Exercise may also help people cope with cue‐induced cravings.10 • Airway resistance refers to a narrowing of the air passages, which in turn affects the rate at which air moves in and out of the lungs. According to the Non‐smokers Movement of Australia, inhalation of smoke from a cigarette can cause a three‐fold increase in airway resistance. Airway resistance is also influenced by other smoking‐related consequences such as tar build‐up and inflammation of the mucous membranes in the respiratory tract, thus making it difficult to obtain the increased amounts of oxygen needed by the body when undertaking activities such as playing sports.11 Appendix A - Resources
23
Physical Activity & Smoking – Key Messages for Patients and the pg.
Public
Helpful Resources • The CAMH (Center for Addiction and Mental Health) Nicotine Dependence Service www.camh.net • Smokers’ Helpline www.smokershelpline.ca (1 877 513‐5333) • Public Health Agency of Canada. Physical Activity Guidelines. http://www.phac‐aspc.gc.ca/hp‐ps/hl‐
mvs/pa‐ap/index‐eng.php • ParticipACTION. http://www.participaction.com • Ontario Ministry of Health Promotion and Sport http://www.mhp.gov.on.ca/en/active‐living/physical‐
activity.asp • The Canadian Society for Exercise Physiology http://www.csep.ca/english/View.asp?x=587 • Act Now BC. How does smoking affect athletic performance? . http://www.actnowbc.ca/families/how_does_tobacco_affect_athletic_performance • NSMA: Smoking and Fitness • http://www.livestrong.com/article/369762‐how‐does‐smoking‐affect‐sport‐
performance/#ixzz1l8g69rRg References 1.
Kaczynski, A. T., Manske, S. R., Mannell, R. C., & Grewal, K. (2008). Smoking and Physical Activity: A Systematic Review. American Journal of Health Behaviour, 32(1), 93‐110. 2. Kujala, U. M., Kaprio, J., & Rose, R. J. (2007). Physical activity in adolescence and smoking in young adulthood: a prospective twin cohort study. Addiction, 102, 1151‐1157. 3. Van Rensburg, K. J., Taylor, A., & Hodgson, T. (2009). The effects of acute exercise on attentional bias towards smoking‐related stimuli during temporary abstinence from smoking. Addiction, 104, 1910‐1917. 4. Taylor, A. H., Ussher, M. H., & Faulkner, G. (2007). The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect and smoking behaviour: a systematic review. Addiction, 102, 534‐543. 5. Williams, D. M., Dunsinger, S., Jennings, E. G., Ussher, M. H., Whitely, J. A., Albrecht, A. E., et al. (2010). Moderate Intensity Exercise as an Adjunct to Standard Smoking Cessation Treatment for Women: A Pilot Study. Psychology of Addictive Behaviors, 24(2), 349‐354. 6. Prapavessis, H., Camerson, L., Baldi, J. C., Robinson, S., Borrie, K., Harper, T. et al. (2007). The effects of exercise and nicotine replacement therapy on smoking rates in women. Addictive Behaviors, 32, 1416‐1432. 7. Katzmarzyk, P., Gledhill, N., & Shephard, R. (2000). The economic burden of physical inactivity in Canada. Canadian Medical Association Journal, 163(11), 1435‐1440. 8. Warburton, D., Nicol, C. W., & Bredin, S. (2006). Health benefits of physical activity: the evidence. Canadian Medical Association Journal, 174(6), 801‐809. 9. Faulkner, G., Taylor, A., Munro, S., Selby, P., & Gee, C. (2007). The acceptability of physical activity in programming within a smoking cessation service for individuals with severe mental illness. Patient Education and Counseling, 66, 123‐126. 10. Arbour‐Nicitopoulos, K. P., Faulkner, G. E., Hsin, A., Selby, P. (in press). A pilot study examining the acute effects of exercise on craving reduction and affect among individuals with serious mental illness. 11. Non Smokers’ Movement of Australia. Fact Sheet – Smoking and Fitness. Available at: http://nsma.org.au/facts/fitness.htm (Accessed April 30, 2012) Appendix A - Resources
24
Physical Activity & Smoking – Key Messages for Patients and the pg.
Public
Oatmeal Buffet
Ingredients:
Bag of quick oats
Milk
Optional Toppings:
Dried fruit and or nuts i.e. cranberries, raisins
Fresh fruit chopped
Yogourt with fruit
Cocoa
Cinnamon
Honey
Directions:
Prepare oats according to package and place optional toppings out for clients to sample on their oatmeal.
Keep your grocery store receipt for all ingredients.
Oatmeal:
Easy and quick to make in a microwave or on a stove
Low cost
Source of fibre and energy
Adding fruit, and milk adds flavour and nutrition
Discussion Points:
Estimated cost – depends on number and type of toppings. Estimated cost for 12 participants $15
Oats
Milk 2 litres
Yogourt
25
Oatmeal pg.
Buffet
Ending the Group
Participating in a successful group experience can be a significant event. It is important that this is
acknowledged in some manner, as it helps to bring a sense of closure and “moving forward”.
• Certificates, and a small celebration (with a snack if possible) is always appreciated, and clearly and
positively marks the ending of the program.
• A final session is also the time to assist participants in clarifying the meaning of their experiences in the
group, consider the changes they have made, and decide which ones, if any, they would like to continue
to work towards.
• Participants may act out of anxiety over an upcoming separation, or stop coming to the final one or two
sessions. Be aware of these potential feelings and when appropriate discuss them with group members.
Some suggested questions might be:
1. “What general effect, if any, has your group experience had on your life?”
2. “What is the one thing you remember most?”
3. “How might your life be different now had you not experienced the group?”
pg. 27
Ending the Group
Tab Appendix B - CO Monitor
Appendix B:
CO Monitor
Aim.Motivation.Choice.Incentive
Resource: Session 1
One of the most deadly chemicals found in cigarette smoke is carbon monoxide (CO). Carbon monoxide is an
odorless and colourless gas. Burning cigars, cigarettes, pipes and cigarillos all produce carbon monoxide.
Carbon monoxide is found in air pollution but the levels absorbed by the body from pollution are very low
compared to the amount in tobacco smoke.
Carbon monoxide takes the place of oxygen in your blood. The body needs oxygen to survive and anything
that decreases the amount of oxygen causes strain on the heart and body.
Over time, the heart has to work harder to deliver oxygen. This puts smokers at greatly increased risk for having
heart attacks.
The Good News about Carbon Monoxide
Although it is very deadly, carbon monoxide lasts only a short time in your body. Your body can eliminate
carbon monoxide within two to three days AFTER you stop smoking. Your carbon monoxide level will go back
down to the same level of somebody who never smoked. The effect of carbon monoxide is reversible and can
get better almost immediately if you stop smoking.
Resource: Session 1
pg. 1
Resource: Session 1
Frequently Asked Questions about breath carbon monoxide (CO) monitoring in smoking cessation.
1. Q – What is carbon monoxide?
A – Carbon monoxide (CO) is a poisonous gas that you cannot smell or see. When someone inhales smoke
from a cigarette, CO is absorbed into their blood through their lungs. CO is dangerous because it binds to
hemoglobin in red blood cells about 200 times as readily as oxygen, depriving the body of vital oxygen to live.
2. Q – What does a breath CO test show?
A – It shows the amount of carbon monoxide in someone’s breath, which is a measure of blood
carboyhemoglobin. It acts as an indicator as to the possible level of some 4000 toxic substances in
cigarette smoke, 60 of which cause cancer.
3. Q – What does ppm mean?
A – Parts per million. In this case, one part CO in one million parts of air (breath). This might not seem like very
much, but ppm has a direct correlation the percentage of CO in someone’s blood. If you give a reading of
20ppm, that of a frequent adult smoker, it means that their oxygen carrying capacity is reduced by 5%.
It also indicates a high level of addiction to nicotine.
4. Q – How quickly does the CO disappear from the body after smoking stops?
A – It takes about 5-6 hours to reduce the original level by half. Usually after a maximum period of 48 hours
the ex-smoker will show the level of a non-smoker living in the same environment.
5. Q – How long after a cigarette should the test be conducted?
A – After 10 minutes.
6. Q – What levels of breath CO do you expect to see?
A – Clinical research has shown that the popular guidelines are:
LED Colour
Description
User Profile 1:
Adult (ppm)
User Profile:
Adolescent (ppm)
Green
Non-smoker
0-6
0-4
Yellow
Danger zone
7-10
5-6
1 Red
Smoker
11-15
7-10
2 Reds
Frequent smoker
16-25
11-15
3 Reds
Addicted smoker
26-35
16-25
4 Reds
Heavily addicted smoker
36-50
26-35
4 Reds flashing
Dangerously addicted smoker
51
36
Resource: Session 1
pg. 2
Resource: Session 1
Client – Frequently Asked Questions (FAQ) (con’t)
7. Q – If a person who smokes reduces their smoking, will this reduce breath CO by an equivalent amount?
A – Probably not. Someone who smokes fewer cigarettes, will require or crave the same amount of
nicotine. Therefore, they may smoke a smaller number, but will smoke aggressively and inhale more smoke
and CO. However, this effect can be offset by the use of nicotine replacement therapy (NRT) which reduces
a person’s craving for nicotine.
8. Q – Is it necessary to hold the breath before taking the test?
A – Not absolutely necessary. For optimum results it is best to hold your breath for 15 seconds. Less than
this will reduce the breath CO reading. However, as long as you exhale completely, the breath sample will
give a good enough reading.
9. Q – Do cigars and pipes give low readings?
A – No, on the contrary: an inhaled puff of pipe or cigar smoke is much more concentrated and will give
surprisingly high CO readings. Marijuana smoking, especially when mixed with tobacco, will also elevate
blood CO.
10. Q – Why do non-smokers sometimes give higher than expected readings?
A – This could be for several reasons:
• They could be exposed to high ambient levels of CO, for example at home or in the car. It could be
useful to check other family members in order to eliminate possible chronic CO poisoning.
• Certain jobs may expose workers to high CO levels. For example, a degreasing agent called
trichloroethylene is metabolized by the liver to produce CO in the blood.
• Other breath components such as alcohol and hydrogen may also interfere with CO monitors.
Hydrogen may be present due to a gut condition called lactose intolerance – an allergy to dairy
products that produces hydrogen gas in the intestine. Some of this gas may be excreted via the lungs.
Smokerlyzers contains filters that prevent alcohol and other organic species – including acetone from
the breath of diabetics – influencing the CO results.
11. Q – How hygienic is the test?
A – A disposable mouthpiece is used for each person taking the test. They are designed to be single-use only.
These mouthpieces usually fit into a device connected to the CO monitor itself. With Smokerlyzers, these
contain one-way valves which stop people sucking air back from the monitors.
12. Q – How fast is the test?
A – A test takes only a few seconds. The operator will take a couple of minutes to instruct you, have you
hold your breath, and to confirm a successful reading.
Citation: Adapted from www.bedfont.com
Resource: Session 1
pg. 3
Resource: Session 1
1. Turn on monitor by holding button for 3 seconds.
2. Attach D-piece and a new mouth piece.
3. Have the client inhale and double-click button to start breath test.
4. Have the client hold breath for a 15 second countdown, and then exhale at a comfortable rate,
making sure to exhale completely. If the client is unable to hold their breath for full 15 seconds,
they should inhale normally, and just when the countdown finishes, exhale fully.
5. The audio beep will sound during the last 3 seconds of the countdown.
6. Have the client blow slowly into mouthpiece, aiming to empty lungs completely.
7. The ppm and (COHb) levels will rise and hold. The coloured LEDs will light accordingly – see chart for
interpretation of readings.
8. Remove D-piece between tests to purge sensor with fresh air.
9. To repeat breath test, double-click button to return to main display and continue from step above.
10. To switch off, hold button for 3 seconds. Unit will auto power off 5 minutes of inactivity.
Citation: Adapted from www.bedfont.com
Resource: Session 1
pg. 4
Resource: Session 1
Monitor: Bedfont CO Monitor (Micro Smokerlyzer™) from McArthur Medical Sales Inc.
About the Monitor: It provides a digital read-out of CO ppm (parts per million) on an easy to read
LCD display together with simple traffic light LEDs and an audible tone. The unit has auto-conversion from
CO ppm to %COHb.
Cost: Approximately $1000 Canadian for monitor and start up supplies.
There are also other monitors available at a reduced cost. There are some differences (i.e. do not have the
digital readout). Clinicians will need to determine what model will best suit the needs of patients/clients and
their work.
Contact Information: Information about this and other products can be accessed through the website at
http://www.mcarthurmedical.com (click on “Hospital”, under “Our Products” on right hand side of page,
then click on “Bedfont Scientific Ltd”, then you will see piCO+™).
1846 5th Concession West
P.O. Box 7
Rockton, Ontario
Canada L0R 1X0
Tel: (519) 622-4030
Toll: 1-800-996-6674 (Canada only)
Fax: (519) 622-1142
E-mail: [email protected]
Resource: Session 1
pg. 5
Tab Appendix C - Forms
Appendix C:
Forms
Ac c e s s. R e c l a i m . E m p o w e r. Po s s e s s
Note: This form can be completed with patient/client prior to MAPP program and updated if more than a
month has passed since initial completion to ensure contact information is current.
Name: ________________________________________ Male: _______ Female: ________ Age: ____________
Patient/Client #: ______________________________________________________________________________
Address: ____________________________________________________________________________________
Phone: _ ________________________________ Email: ______________________________________________
Best way to be reached: _ ______________________________________________________________________
Transportation: _ _____________________________________________________________________________
Assessment completed by: ______________________________________ Date: __________________________
Location: _ __________________________________________________________________________________
Referral Source
� Psychiatrist
� Mental Health Worker
� Addiction Services Worker
� Nurse Practitioner
� Physician
� Pharmacist
� Other ___________________
� Self-referral
Dependence History
1. A. How soon after you wake up do you smoke your first cigarette?
� After 60 minutes (0)
� 31 – 60 minutes (1)
� 6 – 30 minutes (2)
� Within 5 minutes (3)
B. Do you find it difficult to refrain from smoking in places where it is forbidden?
� Yes (1)
� No (0)
C. Which cigarette would you hate to most give up?
� The first in the morning (1)
� Any other (0)
D. How many cigarettes per day do you smoke?
� 10 or less (0)
� 11 – 20 (1)
� 21 – 30 (2)
� 31 or more (3)
E. Do you smoke more frequently during the first hours after awakening than during the rest of the day?
� Yes (1)
� No (0)
F. Do you smoke if you are so sick that you are in bed most of the day?
� Yes (1)
� No (0)
Fagerstrom Score for Nicotine Dependence (FTND) Add #’s for responses A through F and total: _ ___ /10
2. Assessing Readiness to Change
A. “Do you consider your smoking a problem?” B. “Are you distressed by your smoking?” C. “Are you interested in change
(stopping or reducing your smoking)?”
D. “Are you ready to change now?”
� Yes
� Yes
� Yes
� No
� No
� No
� Don’t know
� Don’t know
� Don’t know
� Yes
� No
� Don’t know
Note: If patient/client answered “no” to 2D, then stop here. Patient/client is not ready for a smoking cessation
program at this time.
Appendix C - Forms
pg. 5
MAPP Assessment Form (con’t)
3. What type of tobacco (or combination) do you use? (Check all that apply)
� Cigarettes
� Chewing Tobacco
� Cigars
� Pipe
� Cigarillos (mini cigars) � Hookah
� E-Cigarettes (with nicotine)
4. Do you use tobacco product alternatives? (Check all that apply)
� E-Cigarettes (without nicotine)
� Any other type of smoking device _________________________________________________________
5. Approximately how much money do you spend on tobacco per week on average? ____________________
6. At what age did you smoke your first whole cigarette?
Years ______________ 7. Does anyone in your household smoke? � No
� Yes
� Don’t remember
8. What are your main reasons for attending the MAPP Program?
� Health reasons
� Generally want to be healthier
� Financial costs – can’t afford it
� Don’t like addictive nature of smoking
� Family member asked me to stop
� Feels socially unacceptable
� Smell of smoking in the house/on clothes, etc.
� Have to go outside all the time
� Other reasons (please specify): _ __________________________________________________________
9. What is the highest grade or level of education you have reached?
� Highest grade (1-12) achieved ____________________________________________________________
� Community/Technical College ____________________________________________________________
� University _ ___________________________________________________________________________
� Other education or training ______________________________________________________________
� Don’t know/No response
10. Did you work at a job or a business at any time in the past 12 months? Please include seasonal work, contract
work, self-employment, babysitting and any other paid work, regardless of the number of hours worked.
� Yes
� No
� Don’t know/No response
11. What is your best estimate of the total income, (before taxes and deductions)?
� $0 – $10,000
� $20,000 – $30,000
� $40,000 – $50,000
� $10,000 – $20,000
� $30,000 – $40,000
� $50,000 – above
� Canada Pension for Disability
� Income Assistance
� Prefer not to say
12. Do you consider yourself to belong to any of the following groups?
� A member of visible minority
� Aboriginal person
� A person with a disability
� A recent immigrant to Canada (in the past 5 years)
� None of the above
� No response
Appendix C - Forms
pg. 6
MAPP Assessment Form (con’t)
13. A. What happened the previous time you stopped smoking or did not smoke for an extended period of time?
_ _______________________________________________________________________________________
B. When was your last stop attempt (approx. date)? _ ____________________________________________
C. Method(s) that you used to stop? __________________________________________________________
D. Duration of stop attempt: ________________________________________________________________
E. Withdrawal symptoms experienced: ________________________________________________________
F. Reason for relapse: ______________________________________________________________________
14. Mental Health Concerns
A. Have you experienced Mental Health issues in the past? � Yes � No
If yes explain: _____________________________________________________________________________
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
B. Are you being treated for any mental health issues at present? � Yes � No
If yes explain: _____________________________________________________________________________
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
Who are your primary therapists or counsellors? (Psychiatrist, Physician or Mental Health staff ) List all.
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
C. What medications are you taking?
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
15. Medical Concerns
Are you experiencing any medical conditions related to your smoking (dental/oral health, digestive,
circulatory issues, respiratory, cardiac, cancer) List all. _ ___________________________________________
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
16. Carbon Monoxide Levels
CO reading on date of assessment: _ __________________________________________________________
17. Optional
Blood Pressure: ___________________________ Pulse: _ ________________________________
18. Other concerns or issues: ___________________________________________________________________
_ _______________________________________________________________________________________
Appendix C - Forms
pg. 7
Date
Dear Health Professional,
One or more of your patients/clients may be taking part in MAPP, A Stop Smoking Program for people living
with Mental Illness. This is a program offered by ____________________________________________________.
The program will be offered for 14 weeks starting ______________________________ (date).
Nicotine Replacement Therapy or pharmacotherapy will be offered free of charge to those who are interested
and take part in the weekly group sessions.
This program has been specifically developed for mental health consumers with a tobacco addiction. It will
provide information on the relationship between tobacco use and mental illness, withdrawal, relaxation,
strategies to control addictive behaviours, physical activity, and healthy eating.
All patients/clients have been advised to speak with their doctor prior to starting Nicotine Replacement
Therapy (NRT). They will be offered the Nicotine Patch, Inhaler, Lozenge, Spray and Gum that they can pick up
at their local pharmacy. If your patient/client wishes to start pharmacotherapy (i.e. Varenicline or Bupropion)
they know that they will need to make an appointment with you to determine if this is an appropriate
prescription for them.
If you have any concerns about the patient’s/client’s medications and the use of NRT or pharmacotherapy, or
any other questions please contact me at the following number ______________________________.
Sincerely,
__________________________
MAPP Facilitator
Appendix C - Forms
pg. 8
Patient/Client #: __________________________
Location: _ ______________________________
Date: ___________________________________
I ___________________________________, do swear/affirm that, as a MAPP Participant, I will protect the
confidentiality of personal information of any person who uses the service of the MAPP program. I will not
disclose such personal information to anyone.
MAPP Participant Signature: _____________________________________ Date: _______________
Facilitator: _ __________________________________________________ Date: _______________
Appendix C - Forms
pg. 1
MAPP Program
Insert address and phone number
Pharmacist Form
Dear Pharmacist:
Date: ___________________________________
Expiry Date: _ ____________________________
Re: _____________________________________
Patient’s/Client’s Name
Based on our assessment, we have determined that pharmaceutical aids such as Nicotine Replacement
Therapy (i.e. patch, gum, lozenge, mouth spray, inhaler) and/or Pharmacotherapy (i.e. Varenicline, Bupropion)
with prescription may be appropriate supplements to this patient’s/client’s participation in this dependence
program. Accordingly, and as per our previously agreed upon agreement, please provide the above named
patient/client with:
One of the following options of Nicotine Replacement Therapies – as stated below.
Appropriate dose of lozenge, gum, inhaler or spray __________
Appropriate dose of patch and lozenge __________
Appropriate dose of patch and gum __________
Appropriate dose of patch and inhaler __________
Varenicline (only if accompanied by an appropriate prescription from a physician) __________
Bupropion (only if accompanied by an appropriate prescription from a physician) __________
Quantity/Duration of supply: _ __________________________________________________________________
Please provide the above noted item(s) at no cost to the patient/client.
Billing: Please verify if this patient/client has a third party plan, which provides partial or full coverage of
the above product(s). If he/she does not have any such coverage, please submit this letter to me (address
below) along with an invoice as previously agreed. If he/she does have third party coverage, please invoice
M.A.P.P. for only the portion of the cost that is not provided under the plan. If your pharmacy does not provide
this service, please let us know immediately so we can make alternate arrangements for our patients/clients.
Name: __________________________________ Name: _____________________________________
MAPP Facilitator: _________________________ MAPP Facilitator: _ ___________________________
Phone: _ ________________________________ Phone: _____________________________________
Invoice address: MAPP Program
Insert address
In partnership with: _ ________________________________________________________________________
Please note that we have not conducted a medical assessment and have in no way determined the medical appropriateness of
these medications for the patient/client. We have recommended to the patient/client that he/she discuss this with a physician.
Our naming it in this letter in no way circumvents that process. Our commitment is simple to cover the costs indicated.
March 2013
Appendix C - Forms
Pharmacist Form
pg. 4
We would like to know what you think of the MAPP program overall (i.e. all of the sessions). Your comments
are important and will help us to improve the program. Please complete this form and drop into the box at the
front of the room. Your answers are confidential.
1. Was the MAPP program helpful in motivating you to attempt to stop smoking?
Yes
No
Please explain ____________________________________________________________________________
_ _______________________________________________________________________________________
2. How helpful was the MAPP program in meeting your goal?
Not helpful
Somewhat helpful
Very helpful
3. What did you like best about the program? (check all that apply)
I was treated with respect
Group support
I didn’t feel pressured/judged by a certain expectation
Facilitator approach
Program binder
Other (please specify) ______________________________________________________________________
4. What didn’t you like about the MAPP program?
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
5. What would you change about the MAPP program?
More information
More support from staff
Location
Nothing
Other (please specify) ______________________________________________________________________
Appendix C - Forms
pg. 2
MAPP Overall Program Evaluation (con’t)
6. (a) Each session was approximately an hour and a half. Was this a good length for each session?
Yes
No
If no, how long should each session be? _______________________________________________________
(b) The program ran for 14 weeks. Is this a good number of weeks?
Yes
No
If no, how many weeks should it be? __________________________________________________________
7. (a) Please rate the helpfulness of the MAPP binder/folder.
Not helpful
Somewhat helpful
Very helpful
(b) Which was your favourite material of the program?
_ _______________________________________________________________________________________
(c) Which was your least favourite material of the program?
_ _______________________________________________________________________________________
8. How would you describe your overall experience with your facilitator(s)?
Poor
Fair
Good
Very Good
9. Is there anything further you would like to add?
_ _______________________________________________________________________________________
_ _______________________________________________________________________________________
Appendix C - Forms
pg. 3
MAPP Educator
Date
“Victory is always possible for the person who refuses to stop fighting.”
Napoleon Hill
Congratulations on successfully completing
Nicotine Dependence Education
Certificate of Completion
Certificate of Completion
pg. 9
Tab Appendix D - References
Appendix D:
References
Consider.Information.Know.Intelligence
References
Print Resources:
Els, C., & Kunyk, D. (2008). Management of tobacco addiction in patients with mental illness. Smoking Cessation
Rounds, 2(2). Retrieved from www.smokingcessationrounds.ca
Els, C. (2009). Tobacco addiction: What do we know, and where do we go? Els, C
Els, C., & Kunyk, D. (2010). Applying a chronic disease paradigm to safe and effective treatment of tobacco
addiction. Canadian Journal of Respiratory Therapy, 46.3.
Els, C., & Kunyk, D., Sidhu, H. (2011, June). Smoking cessation and neuropsychiatric adverse event. Canadian
Family Physician, 57, 647-649.
Prochaska, J.J. (2011, July). Smoking and mental illness: Breaking the link. The New England Journal of Medicine,
353-3
Sellman, D. (2009). The 10 most important things known about addiction. Addiction, 105, 6-13
Williams, J.M. (2007). Using peer counselors to address tobacco use: the choices program. Psychiatric Services,
58(9), 1225.
Williams, J.M., & Gnadhi, K.K. (2008). Use of caffeine and nicotine in people with schizophrenia. Current Drug
Abuse Reviews, 1, 155-161.
Williams, J.M., Zimmermann, M.H., Steinberg, M.L., Gandhi, K.K., Delnevo, C., Steinberg, M.B., & Foulds, J. (2010).
A comprehensive model for mental health tobacco recovery in new jersey. Adm Policy Mental Health.
Print Resources
pg. 1
References
Selected Smoking Cessation Web Resources:
Alberta Quits. (2012). The barb tarbox story. Retrieved from http://www.albertaquits.ca/quit_stories/barb_
tarbox.php
CAN-ADAPTT. (2011). CAN-ADAPTT Canadian Smoking Cessation Clinical Practice Guideline. Toronto Canada:
Canadian Action Network for Canadian smoking cessation clinical practice guidelines. Retrieved from
www.can-adaptt.net
Canadian Cancer Society. (2012). Smoking and tobacco. Retrieved from www.cancer.ca
Canadian Cancer Society. (2012). Smokers’ Helpline. Retrieved from www.smokershelpline.ca
Centre for Addiction and Mental Health. (2012). Retrieved from www.camh.net
Els,C., Kunyk, D., & Shelby, P. (2012). Disease Interrupted: Tobacco reduction and cessation. Retrieved from http://
diseaseinterrupted.com
Health Canada. (2012). Health concerns: Tobacco. Retrieved from www.healthcanada.gc.ca/tobacco
Mayo Clinic. (2013). Nicotine dependence center. Retrieved from http://ndc.mayo.edu/
Propel Centre for Population Health Impact. (2012). Tobacco use in Canada patterns and trends. Retrieved from
http://www.tobaccoreport.ca/2012/index.cfm
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References
Extra Articles:
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Extra Articles
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Extra Articles
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MAPP Program Manual - Nicotine Dependence Clinic

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