stop smoking interventions smokefree nurses auckland march 19th 2015 mark wallace-bell phd rn
TRANSCRIPT
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
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
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