Stop Smoking Interventions Smokefree Nurses Auckland March 19th 2015 Mark Wallace-Bell PhD RN.

Stop Smoking Interventions

Smokefree Nurses

Auckland March 19th 2015

Mark Wallace-Bell PhD RN

Hayden McRobbieRobert WestChris Bullen

Acknowledgements

● Quick review of the NZ guidelines● ABC interventions● New research on E-cigs● Nursing interventions for stopping smoking● Empathy and therapeutic relationships● Questions

Outline

The NZ guidelines

ABC for health care professionals:● New 2014 guidelines

o largely adopted into routine practice

o MH and Addictions ?● Health Targets- Secondary

care● Health Targets- Primary care

*To achieve the 2025 goal the net annual cessation rates must increase to:

*10% in non-Maori (2-3 x current rate)

*20% in Maori

Business-as-usual forecast of smoking prevalence

Ikeda T, et al. Tob Control 2013;0:1–7.

Smokefree 2025

‘The first law of smoking cessation’

Professor Robert West, UCL

E = N x Snumber of ex-

smokers created in a given time

period

number of smokers

who try to stop

probability of success in those who

try

Increasing the number of Ex smokers

Li, J., & Newcombe, R. (2013). Past 12-month quit attempts and the use of cessation aids. [In Fact]. Wellington: Health Promotion Agency Research and Evaluation Unit.

Clients who used multiple Quitline service types were more likely to succeed.

At 6 months the quit rate for clients who had used:

– phone support was 20.9%

– online support was 26.6%

– phone and online support was 33.46%

– phone and online and text support was 37%

Multiple approaches work

E-cigs or ENDS

● Not an approved stop smoking medication in NZ

● Can be legally purchased online for personal use

● Sold in NZ but not with nicotine● Long term health effects not known

Caponnetto (2013)(PlosOne)

Bullen (2013)(Lancet)

Population Unmotivated to quit Motivated to quit

Inclusion criteria ≥10cpd for at least 5 years, 18-70 years ≥10cpd for last year, ≥18 years

Brand Categoria Elusion

Sample size 300 657

Intervention 7.2 mg E-cig7.2-5.4 mg E-cig

0 mg E-cig

No behavioural support

16mg E-cig21mg NRT patch

0mg E-cig

Minimal behavioural support

Intervention period 12 weeks 13 weeks (includes one week pre-quit)

Follow-up 12 months 6 months

Power 75% 80%

Primary outcome Verified continuous abstinence at 6 months Verified continuous abstinence at 6 months

McRobbie, Bullen etal (2013) Meta-analysis

Cessation – Nicotine vs Non-Nicotine e-cigarettes

Study Nicotine EC Placebo EC RR (95% CI)

Bullen 2013 7% (21/289) 4% (3/73) 1.77 (0.54 – 5.77)

Caponnetto 2013 11% (22/200) 4% (4/100) 2.75 (0.97 – 7.76)

Total 9% (43/489) 4% (7/173) 2.29 (1.05 – 4.96)

Conclusions• Limited evidence from one RCT that nicotine containing e-

cigarettes give similar quit rates at 6 months as NRT. • Smokers who used nicotine e-cigarettes were significantly more

likely to stop smoking than smokers using placebo e-cigarettes.• The effect size (5%) is small, but not unexpected given the low

level of behavioral support provided• Nicotine EC were significantly more effective than placebo EC and

also significantly more effective than nicotine patches in helping people achieve 50% or greater reduction in smoking

Don’t forget behavioural support

● Strengthen ex-smoker identity

● Measure CO● Reward abstinence● Advise on changing

routine● Advise on coping with

cravings

● Advise on medication use

● Ask about experiences when using medication

● Give options for additional support

● Elicit client views

Summary● Behavioural support via websites, written materials and text messaging

can be effective; smartphone apps yet to be adequately tested● All available pharmacotherapies are safe● The most effective pharmacotherapy options are varenicline or dual form

NRT with some professional support● The most acceptable is NRT over the counter but it has low effectiveness

possibly due to poor adherence (UK evidence)● For the future, cytisine offers the prospect for an affordable, acceptable,

practicable and effective pharmacotherapy● ENDS or ‘vaping’

o not inferior to NRTo may not be better? few studies to date

Stop Smoking Interventions by nurses

Rice and Stead (2009) Cochrane Review:● 42 studies included● Interventions by nurses and health visitors● Compared to control or usual care● Nursing intervention was defined as the

provision of advice, counselling, and/or strategies to help patients quit smoking.

● Did not evaluate effectiveness of NRT

Hypotheses investigated

● Interventions by nurses;o are more effective than no intervention?o are more effective if the intervention is more intense?o differ in effectiveness with health state and setting of the

participants?o are more effective if they include follow ups?o are more effective if they include aids that demonstrate

the pathophysiological effect of smoking?

Authors Conclusions:

The results indicate the potential benefits of smoking cessation advice and/or counselling given by nurses to patients, with reasonable evidence that intervention is effective. The evidence of an effect is weaker when interventions are brief and are provided by nurses whose main role is not health promotion or smoking cessation. The challenge will be to incorporate smoking behaviour monitoring and smoking cessation interventions as part of standard practice, so that all patients are given an opportunity to be asked about their tobacco use and to be given advice and/or counselling to quit along with reinforcement and

follow up.

Plain Language SummaryMost smokers want to quit, and may be helped by advice and support from healthcare professionals. Nurses are the largest healthcare workforce, and are involved in virtually all levels of health care. This review found that advice and support from nursing staff could increase people’s success in quitting smoking, especially in a hospital setting. Similar advice and encouragement given by nurses at health checks or prevention activities seems to be less effective, but may still have some impact.

Conclusions...

● ABC working to prompt more quit attempts● NRT and other pharmacotherapy is most

effective when combined with behavioural support

● Nurse led interventions are beneficialo but better when properly time resourced and

delivered by specialist practitioners

What about Interpersonal factors?

● Pharmacotherapy works● Behavioural support

works BUT● The quality of the

practitioners empathy is a strong therapeutic element

Therapeutic relationships

"...In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?"

----Carl Rogers, On Becoming a Person.

What is empathy?

commitment to understanding the client's personal frame of reference and the ability to convey this heard meaning back to the client via reflective listening....the process encompasses the accurate understanding of both cognitive and emotional aspects of the client's experience as well as attunement to the unfolding experience of a client during a treatment session."

Moyers, T.B., & Miller, W.R., (2012, October 1), Is Low Therapist Empathy Toxic? Psychology of Addictive Behaviors,

27, 878-884.

What is empathy?

● Ability to be present● Ability to recognize, perceive and, to some

degree, directly experientially feel the emotion of another

● Ability to convey understanding without judgment

● Ability to remove blocks to connection and action

Empathy is not….

● Sympathy: “I'm sorry you’re sad.”● Emotional Contagion: “I feel sad too.”● Apathy: “I don't care how you feel.”● Telepathy: “I read your sadness without you

expressing it to me in any normal way.”● Just listening

Perceptions matter

Client perceptions of therapist empathy are directly correlated with more positive outcomes.

Empathy is more important than your technical orientation

Empathy better than self-help and low empathy

Studies have found that clients would have had better

outcomes with a self-help book than a low-empathy

therapist, while high-empathy therapists were far superior

to bibliotherapy. The trends of these results have continued

to the present, show variability between therapists having

more to do with outcomes than differences between clients

(Baldwin et al, 2007).

We are looking in the wrong direction

Too little attention has been paid to the therapeutic and healing qualities of the therapist administering a range of either assessment or treatment protocols.

Placebo effect Nocebo Effect (I will please) (I will harm)A fake treatment, an inactive substance like sugar, distilled water, or saline solution -- can sometimes improve a patient's condition simply because the person has the expectation that it will be helpful.

A negative effect that occurs after receiving treatment (therapy, medication), even when the treatment is inert (inactive, sham). The person has a negative expectation of outcome

Placebo and Nocebo effects

A cold, uncaring, disinterested and emotionless physician will encourage a nocebo response. In contrast, a caring, empathetic, physician fosters trust, strengthens beneficent patient expectations, and elicits a strong placebo response. A compassionate, hands-on approach may be more valuable than any single medical therapy.

Conclusions….

As well as the technical elements of any intervention to help people change behavioursempathy and the ability to communicate accurate understanding of your patients experience is an important aspect of nursing interventions

Conclusions….

1) High-empathy counselors appear to have higher success rates regardless of their therapeutic practice2) Training therapists in how to be highly empathic may contribute to better treatment outcomes.3) Use the placebo effect

Final words...

Imagine the future of health care relegated to a series of guide-lines,tests,algorithms,procedures,and drugs without the human touch. Healthcare,rendered by a faceless,uncaring army of protocol aficionados,will miss an opportunity to deliver an effective placebo response.Wise placebo use can benefit patients and strengthen the medical profession(Olshansky, B.Journal of Cardiology, 2007;49:415-21)

Motivational Interviewing in Action

How to help people change

Behavioural Change

MI in New Zealand

Miller and Rollnick’s Definition of MIMI is a collaborative, goal-oriented style of communication with particular attention to

the language of change. It is designed to strengthen personal motivation for and

commitment to a specific goal by eliciting and exploring the person’s

own reasons for change within an atmosphere of acceptance and

compassion

MI Spirit

Partnership

Acceptance

Evocation

Compassion

If someone else voices an argument for change, people are likely to respond by expressing a

counter-change argument from the other side of their ambivalence.

People literally talk themselves out of changing.

Similarly, people talk themselves into changing by continuing to voice pro-change

arguments.

Core Skills

●Asking Open-ended questions

●Affirming

●Reflective Listening

●Summarizing

&●Informing and Advising

Informing and Advising

●In MI, providing information and advising is appropriate, with two considerations:1. Information and advice are offered with permission2. The goal for the counselor is to understand the client’s

perspective of the topic, their needs, and to facilitate the client drawing their own conclusion about the relevance of any information provided

Behind closed doors

Idea/ concept Motivational Interviewing

1. Identical to Rogers’ non-directive counseling

2. A technique or gimmick to make people change

1. MI’s focusing, evoking, and planning have clear directionality to them.2. MI was specifically developed to help clients resolve ambivalence and strengthen their own commitment to change

MI: Is NOT/ Does NOT:

Idea/ concept Motivational Interviewing

3. MI is a panacea, the solution to all clinical problems

3. MI blends well with other approaches and does not negate the value of other techniques. MI is a style of being with people, an integration of clinical skills to foster movement for change.

MI: Is NOT/ Does NOT:

Idea/ concept Motivational Interviewing

4. The Transtheoretical Model (TTM), although they are compatible and complementary.5. The “Decisional Balance” technique exploring the pros and cons of change

4. TTM defines stages of change while MI provides a means of moving through the stages5. Decisional balance is more associated with counseling with neutrality as the counselor explores con’s of change. MI is more directional, with the intent being to strengthen the arguments for change

MI: Is NOT/ Does NOT:

Idea/ concept Motivational Interviewing

6. Require the use of assessment feedback7. A way of manipulating people into doing what you want them to do

6. While personal feedback may be particularly useful for persons who aren’t considering change, it is not a necessary nor a sufficient component of MI.7. MI cannot be used to manufacture motivation that isn’t already there. It is a collaborative partnership that honors and respects the other’s autonomy, seeking to understand the person’s internal frame of reference.

MI: Is NOT/ Does NOT:

Motivational Interviewing

SpiritPartnershipAutonomyCompassionevocation

PrinciplesExpress EmpathySupport Self-efficacy

Change Talk

Preparatory &Implementing

Change

Core Counselling SkillsOpen Questions

AffirmReflections

Summary Statements