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					        Keep Our University
        Free From Smoking
Submitted To King Saud University Program:

    Smoke - Free Environment
       Ata Ulhaq, MD, FACEP, MPH




                     2009 Atwood & Clark
                         Consultants
                Smoking Cessation
                [stopping smoking]
 Represents the single most important step to enhance
  length and quality of life
 Quitting smoking is not easy, but you can do it
 To have the best chance of success in quitting, you
  need to know:
      what you're up against
      what your options are
      where to go for help


                       2009 Atwood & Clark Consultants
           Pathology of Smoking
 Acute myeloid                       Macular
  leukemia                             degeneration
 Alzheimer’s                         Rheumatoid
 Lupus                                arthritis
 SIDS                                Acid reflux
 Colic in babies                     Breast cancer
 Impotence                           Depression
 Various cancers                     Thyroid disease

                    2009 Atwood & Clark Consultants
     Cardiovascular Pathology
•   Firmly established risk factor for
    coronary heart disease and peripheral
    vascular disease
•   Twofold or greater risk of coronary heart
    disease among smokers
•   Severe atherosclerosis of the abdominal
    aorta
     much greater risk of aortic aneurysm
     peripheral vascular disease
                 2009 Atwood & Clark Consultants
Atherosclerosis

                 development of
                     atherosclerosis in
                     an artery




 2009 Atwood & Clark Consultants
           Physiologic Responses
•   Accelerating atherogenesis or increasing the
    probability of thrombosis
       reduction in plasma high-density
       lipoprotein cholesterol concentration
       elevation in plasma fibrinogen
    concentration
       elevation in white blood cell count

                 2009 Atwood & Clark Consultants
Smoker vs. Non Smoker


                 31 year old non-smoker

                  30 year old smoker



     2009 Atwood & Clark Consultants
              Reversible
 The rapid amelioration of the risk of
  cardiovascular disease after cessation
  of smoking suggests that these
  processes are readily reversible




             2009 Atwood & Clark Consultants
                   Cancers

 Aside from the
  obvious lung
  cancer,
  smoking
  contributes to
  many other
  cancers of the
  body

             2009 Atwood & Clark Consultants
Cancer of the Oral Cavity




    2009 Atwood & Clark Consultants
   Pharynx




2009 Atwood & Clark Consultants
Esophagus




2009 Atwood & Clark Consultants
Stomach




2009 Atwood & Clark Consultants
 Bladder




2009 Atwood & Clark Consultants
   Cervix




2009 Atwood & Clark Consultants
          Kidney Cancer
Advanced renal
 carcinoma




                            Papillary renal carcinoma


            2009 Atwood & Clark Consultants
Pancreas




2009 Atwood & Clark Consultants
       Carbon Monoxide - CO
 What Carbon
  Monoxide is:
     CO is a poisonous,
      colorless, odorless
      gas produced as a
      result of incomplete
      burning of carbon-
      containing fuels

                2009 Atwood & Clark Consultants
                    CO
 What Happens When CO is Inhaled:
     When inhaled, CO quickly binds with
      hemoglobin in red blood cells in the lungs,
      creating COHb
     This can affect the amount of hemoglobin
      available for the transport of oxygen
      throughout the body
     May in turn lead to symptoms of CO
      poisoning

                2009 Atwood & Clark Consultants
       Carbon Monoxide in
        Cigarette Smoke
 Cigarette smoke can contain high levels
  of carbon monoxide
 Smokers generally have COHb levels in
  the blood that are many times greater
  than those who do not smoke


              2009 Atwood & Clark Consultants
    CO and Secondhand Smoke

 Because secondhand smoke may also
  contain high levels of CO, nonsmokers who
  breathe in ETS (Environmental Tobacco
  Smoke) have increased levels of CO in their
  blood as well



               2009 Atwood & Clark Consultants
      CO and Secondhand Smoke

 Secondhand smoke is a toxic cocktail of:
     over 4,000 chemical compounds
     200 of which are known to be poisonous
     upwards of 60 that have been identified as
      carcinogens




                   2009 Atwood & Clark Consultants
       Smoking During Pregnancy

 When a pregnant woman smokes, her baby does too
 Poisons like carbon monoxide and nicotine travel to
  the growing baby
 Prevents as much as 25 % of oxygen from reaching
  the placenta
 Keeps baby from getting enough food
 More likely to deliver early or baby of low birth
  weight


                   2009 Atwood & Clark Consultants
     Smoking and Pregnancy

 Mothers can pass nicotine through breast
  milk
 Nicotine can be found in mucus from the
  cervix of a female smoker
 Nicotine freely crosses the placenta and
  has been found in amniotic fluid and the
  umbilical cord blood of newborn infants
              2009 Atwood & Clark Consultants
    Smoking During Pregnancy, cont’d.

 Children born to women who smoked during
  pregnancy are more likely to develop asthma
  and other lung problems as they grow older
 May learn more slowly
 Infants are more likely to develop colds,
  bronchitis, and other respiratory diseases if
  secondhand smoke is present in the home

                2009 Atwood & Clark Consultants
       Smoking and Women
 Female smokers are nearly 13 times more likely to
  die from COPD
 Smoking is directly responsible for more than 90% of
  chronic obstructive pulmonary disease (COPD), or
  emphysema and chronic bronchitis deaths each year
 Women who smoke also have an increased risk for
  developing cancers of the oral cavity, pharynx, larynx
  (voice box), esophagus, pancreas, kidney, bladder,
  and uterine cervix

                   2009 Atwood & Clark Consultants
     Smoking and Women
 Women who smoke double their risk for developing
  coronary heart disease
 Postmenopausal women who smoke have lower
  bone density
 Women who smoke have an increased risk for hip
  fracture
 Cigarette smoking also causes skin wrinkling that
  could make smokers appear less attractive and
  prematurely old

                 2009 Atwood & Clark Consultants
       Smoking and Women

 Women who quit smoking relapse for
  different reasons than men
  
    Stress
  
    Weight control
  
    Negative emotions


                2009 Atwood & Clark Consultants
         Smoking Among Seniors

 Seniors face increased risks associated with
  smoking
      hip fractures (both men and women)
      Cataracts

      COPD

      Smoking reduces bone density among menopausal
       women
      nuclear cataracts of the lens of the eye (2-3 times the
       risk of nonsmokers)

                     2009 Atwood & Clark Consultants
Thank You


   2009 Atwood & Clark
       Consultants
Nicotine and Addiction

          Part II




        2009 Atwood & Clark
            Consultants
Nicotine & Addiction

         Why is quitting and staying
         quit hard for so many people?

         Answer = Nicotine




     2009 Atwood & Clark Consultants
          Addiction
 Compulsive physiological/psychological
  need for a habit-forming substance
 Dependence on a behavior or substance that
  one is powerless to stop
 One of the most costly public health
  problems


              2009 Atwood & Clark Consultants
              Addiction
 A progressive syndrome; increases in
  severity over time unless treated
 Characterized by frequent relapse, or return
  to the abused substance
 Abusers often make repeated attempts to
  quit before they are successful


               2009 Atwood & Clark Consultants
        Nicotine & Addiction
Nicotine:
   Drug found naturally in tobacco
   Highly addictive -- as addictive as heroin or cocaine
   Over time, a person becomes physically/emotionally
    addicted to nicotine
   Studies show smokers must deal with both the
    physical and psychological (mental) dependence to
    quit and stay quit

                    2009 Atwood & Clark Consultants
        Physical Dependence
 “the appearance of characteristic
  withdrawal symptoms when the use of a
  substance is suddenly discontinued"
 Nicotine is considered physically addictive
  because it physically alters your brain
  function
 It produces withdrawal symptoms when you
  stop smoking

               2009 Atwood & Clark Consultants
           Physical Dependence
 Physical dependence is defined by the appearance of
  withdrawal symptoms when use is discontinued
        Opiates (such as Herion)
        Benzodiazepines
        Barbiturates
        Alcohol
        Nicotine



     Induce physical dependence


                       2009 Atwood & Clark Consultants
   Physiological Effects

 When you inhale, nicotine is carried deep
  into your lungs
 Absorbed quickly into the bloodstream
 Nicotine inhaled reaches the brain faster
  than drugs that enter the body intravenously
  (IV)


             2009 Atwood & Clark Consultants
       Physiological Effects
 Nicotine affects many parts of the body:
     heart
     blood vessels
     hormones
     metabolism
     brain



                      2009 Atwood & Clark Consultants
    Physiological Effects cont’d.

Nicotine produces pleasant feelings
Makes the smoker want to smoke
 more




             2009 Atwood & Clark Consultants
     Physiological Effects cont’d.

 Acts as a depressant by interfering with
  the flow of information between nerve
  cells
 As the nervous system adapts to
  nicotine, smokers increase the number of
  cigarettes they smoke
 This, in turn, increases the amount of
  nicotine in the smoker's blood
               2009 Atwood & Clark Consultants
        Withdrawal Symptoms
 dizziness (which may                   sleep disturbances, i.e.
  only last 1 to 2 days                   trouble falling
  after quitting)                         asleep/staying asleep,
 depression                              bad dreams or even
 feelings of frustration,                nightmares
  impatience, and anger                  trouble concentrating
 anxiety                                restlessness
 irritability                           headaches
 increased appetite                     tiredness

                   2009 Atwood & Clark Consultants
    Psychological Addiction
 Much more complex than physical addiction
 Does not involve the nicotine in cigarettes or
  the physical effects the nicotine has on your
  brain
 Psychological dependence transpires when a
  person develops a daily routine and a habit
  of actually smoking the cigarettes


                2009 Atwood & Clark Consultants
           Psychological Addiction:
                  Pleasure
 Smoking gives pleasure
 This "pleasure" comes in many ways:
     the tactile pleasure of handling the cigarette
     oral pleasure of drawing on the cigarette
     "quick fix" in times of anxiety
     anger and stress
     social pleasure of smoking in situations of good
      feelings such as bars, pubs or sporting events.

                     2009 Atwood & Clark Consultants
     Addiction: Psychological Aspects

 To feel good (sensation seeking)
 To feel better (self-medicating)
 Move quickly from the voluntary period of
  drug use to compulsive behavior motivated by
  craving



                2009 Atwood & Clark Consultants
   Addiction: Psychological Aspects

 Loss of control over use
 Continued use despite negative physical and
  social consequences
 Believed to be strongly associated with
  brain’s reward system



              2009 Atwood & Clark Consultants
    Psychological Dependence
 Dependency of the mind
 Leads to psychological withdrawal
  symptoms
     Cravings
     Irritability

     Insomnia

     Depression

     Anorexia, etc.

 Addiction can be derived from any
  rewarding behavior
                2009 Atwood & Clark Consultants
       Psychological Triggers
 These triggers are usually brought on by
  stressful situations such as an argument,
  vehicle accident, not getting enough
  sleep or other demanding situations
 You need to be able to recognize these
  stressful situations and react to them
  appropriately

               2009 Atwood & Clark Consultants
      Psychologically Hooked
 Over time, you become used to smoking in these
  situations
 Your mind associates smoking with them and the
  pleasure that comes with them
 You find yourself lighting up even if you aren't
  physically craving the nicotine...without even
  thinking about it!
 At this point, you are psychologically hooked

                  2009 Atwood & Clark Consultants
             Why People Start
            & Continue Smoking
           Start                                     Continue
 Desire to look cool                      Physical addiction
 Seduced to try tobacco by                Mental addiction
  glamorization of smoking in
  movies and advertisements                Stress
 Peer pressure                            Around other
 Rebellion                                 smokers
 Poor coping skills                       Rely on pills/patches
 Social habit became                       rather than willpower
  addiction
                   2009 Atwood & Clark Consultants
 You Generally Start Smoking

in an attempt to…
 change your self-image
 appear more attractive
 more manly
 more feminine
 more intelligent
            2009 Atwood & Clark Consultants
      Sometimes You Start Smoking
in a misguided attempt to…
 calm your nerves
 cope with stress
 lose weight

      Smoking does not help solve the source
        of your problems or compensate
             for poor eating habits

                 2009 Atwood & Clark Consultants
      Other Reasons for Smoking
   On a dare to show you are not timid or afraid
   To fit with the crowd (all my friends do it)
   To appear sophisticated or cool
   To be grown-up
   To assert your independence
   As a sign of protest, rebellion, or to defy authority
   Free samples from friends or advertisers


                    2009 Atwood & Clark Consultants
   Still More Reasons…
 Influences from people you respect and
  admire
 Parents or relatives smoked
 Images of famous actors, movie stars, or
  role models



             2009 Atwood & Clark Consultants
     Still More Reasons…
 Sports players who use chewing tobacco
 Famous scientists
  (Einstein is the prototype of intellectual
  smokers; he looks so proud with a pipe in his
  mouth)
 Portrayals by cigarette advertisements
 As a kind of "air freshener" when using the
  toilet

               2009 Atwood & Clark Consultants
       Reasons for Continuing

   No particular reason, but the cigarettes are handy
   To reduce a feeling of anxiety or nervousness
   To calm down when upset or angry
   To socialize with other smokers
   When feeling restless
   As relaxation



                   2009 Atwood & Clark Consultants
  Reasons for Continuing Cont’d.
 To take a break from work
 While having coffee or tea
 When having a drink with friends
 To satisfy an urge to smoke
 After a meal


           2009 Atwood & Clark Consultants
  Reasons for Continuing Cont’d.

 To pass the time while waiting for
  someone
 When driving in the car
 When feeling depressed
 When drinking beer, wine, or liquor
 To celebrate something
 To think about a difficult problem

            2009 Atwood & Clark Consultants
              You Have Been
            Smoking for a While
 Now you know that smoking has not made you
      Smarter
      Cooler

      Sexier

 Smoking has not helped you to achieve your goals
 You are more aware your health suffers
      Burning eyes
      Hacking cough

        Phlegm in your throat                         So…

                     2009 Atwood & Clark Consultants
     Why Do You Still Smoke?

 Out of habit
 People smoke under specific situations
  as a kind of ritual
 Associating activities with smoking
  establishes Pavlovian reflexes


             2009 Atwood & Clark Consultants
          Pavlovian Reflexes
 Named after Dr. Ivan Pavlov who was able to
  make his dogs salivate in the absence of food by
  just ringing a bell that had been associated with
  the dog's feeding time
 In the same way, activities you associated with
  smoking (drinking coffee) will act as triggers
 The mere sight of a cup of coffee will cause you to
  reach for your cigarettes without any conscious
  thought

                  2009 Atwood & Clark Consultants
                Triggers
 Seeing friends
  smoking cigarettes
 Watching movies
  where actors smoke
 Smell of cigarette
  smoke may trigger
  the psychological
  desire to smoke
              2009 Atwood & Clark Consultants
The Insular
            Researchers found smokers
             with a damaged (due to
             stroke) insula, a region of
             the brain linked to emotion
             and feelings, quit smoking
             easily and immediately
            Provides direct evidence that
             addiction to nicotine takes
             control of some of the neural
             circuits in the brain
2009 Atwood & Clark Consultants
Ventral Tegmental Area
                   Brain’s reward circuit are
                    located along the medial
                    forebrain bundle (MFB)
                   Brain’s punishment circuit
                    (the periventricular system,
                    or PVS) enables us to cope
                    with unpleasant situations
                   Two major systems of
                    motivation in humans
     2009 Atwood & Clark Consultants
        Ventral Tegmental Area
 Neurobiological foundations of addiction
  traced to the VTA – “reward circuit”
 Reward system in the brain is activated when
  a person performs an action necessary to
  survival, such as eating
 Activation of the reward circuit provides
  pleasurable feelings, gives positive feedback

                 2009 Atwood & Clark Consultants
       Ventral Tegmental Area
 Most abused drugs stimulate the reward system
 Provide greater pleasure than normally the result of
  natural stimulation
 The reward system underlies addiction to tobacco
 Many drugs cause physical addiction by affecting
  the levels of neurotransmitters, specifically
  dopamine and glutamate, in the reward circuit of the
  VTA

                  2009 Atwood & Clark Consultants
               Epinephrine
 Immediately after exposure to nicotine, there
  is a "kick" caused by stimulation of the
  adrenal glands and resulting discharge of
  epinephrine (adrenaline)
 This stimulates the body causing a sudden
  release of glucose, and an increase in blood
  pressure, respiration, and heart rate

                 2009 Atwood & Clark Consultants
          Norepinephrine
 Nicotine also suppresses insulin output from
  the pancreas, which means smokers are
  always slightly hyperglycemic
 Nicotine stimulates specific excitatory
  systems in the brain
 These systems excite not only dopamine but a
  host of other brain chemicals, such as
  norepinephrine and serotonin

                2009 Atwood & Clark Consultants
         Acetylcholine
 Every nerve in your brain and nervous system
  communicates with other cells by sending out tiny
  neurotransmitters (chemical messengers)
 These are received by the receptors of the other cell
 Nicotine acts on the receptors that are normally used by
  a main neurotransmitter called acetylcholine
 Essentially tricking your body into thinking the nicotine
  is extra acetylcholine

                     2009 Atwood & Clark Consultants
        Acetylcholine
When you started smoking, your
 body began responding to the
 nicotine thinking it was extra
 acetylcholine



           2009 Atwood & Clark Consultants
            Acetylcholine
 As you continued to smoke, your body
  began to adapt to this "extra"
  acetylcholine
 How?
     By growing extra acetylcholine receptors!
      This is the way that nicotine physically
      alters your brain function


                 2009 Atwood & Clark Consultants
              Acetylcholine
 Over the years, your body has become used to what it
  thinks is a normal level of acetylcholine
 If you were to suddenly stop smoking, your body
  would react, thinking it was being deprived of this
  neurotransmitter
 Seeking equilibrium, subconsciously your body tells
  you that you must get more acetylcholine
 This is where the craving for nicotine comes from

                   2009 Atwood & Clark Consultants
           Acetylcholine
 After a day or two of not smoking, cells
  begin adapting again by decreasing the
  amount of acetylcholine receptors
 Nicotine cravings begin to subside
 In fact, the physical addiction to nicotine
  can be broken in a matter of days


               2009 Atwood & Clark Consultants
           Acetylcholine
 So why is smoking considered so difficult
  to give up if nicotine addiction is gone in a
  few days?
 Breaking the physical addiction to nicotine
  is actually half the battle




               2009 Atwood & Clark Consultants
            Treatment


  Once the foundations of
understanding addiction have
 been laid, the next obvious
 question is how to treat it.


       2009 Atwood & Clark Consultants
              Seven Phases of
            Behavior Modification
1. Pre-contemplation: smoking isn't a
   problem
2. Contemplation: smoking has
   disadvantages, but I'm not yet ready to quit
3. Preparation: you want to quit and you
   prepare to quit


                2009 Atwood & Clark Consultants
         Seven Phases of
       Behavior Modification

4. Action: you stop smoking
5. Maintenance: you are more
   comfortable as a non-smoker
6. Termination: you are a non-smoker
7. Relapse: Back to Phase 2



            2009 Atwood & Clark Consultants
             B. F. Skinner
 Behavior modification is based on the
  principles of operant conditioning
 Developed by American behaviorist B. F.
  Skinner (1904-1990)
 Formulated the concept of operant
  conditioning


              2009 Atwood & Clark Consultants
              B. F. Skinner
 Behavior shaped by reinforcement or lack of
  it
 Considered his concept applicable to a wide
  range of both human and animal behaviors
 Introduced operant conditioning to the
  general public in his 1938 book, The
  Behavior of Organisms

               2009 Atwood & Clark Consultants
      Behavior Modification

 Behavior modification is a treatment
  approach
 Based on the principles of operant
  conditioning
 Replaces undesirable behaviors with more
  desirable ones through positive or negative
  reinforcement

               2009 Atwood & Clark Consultants
       Behavior Modification
   Positive incentives
   Negative incentives/Aversive techniques
   Self-monitoring-keeping a “smoking diary”
   Step-wise decreasing of agent (nicotine)
   Stimulus control
   Contingency management-drawing up contract
   Coping skills
   Peer pressure

                  2009 Atwood & Clark Consultants
         Successful Behavior
            Modification
 The success of this approach/technique
  is dependent on the following
  environments:
     Psychosocial

     Economical

     Religious

     Political

     Educational


                    2009 Atwood & Clark Consultants
    Positive Reinforcement
 Encourages certain behaviors through system of
  rewards
 Draw up a contract with the client establishing
  terms of the reward system
 Small rewards or recognition programs (t-shirt, pin,
  certificate)
 Providing nicotine replacement products at no cost
 Reducing insurance premium differentials between
  smokers and non-smokers

                 2009 Atwood & Clark Consultants
     Additional Incentives
 Adding cash to a flexible spending account to
  pay for enrolling in a tobacco cessation
  program
 Joining program gets reward
 Anything economically and socially
  acceptable
 Academic reward
 Different incentives at different stages

                2009 Atwood & Clark Consultants
    Negative Reinforcement
 Another behavior modification technique
  is negative reinforcement
 Method of training that uses a negative
  reinforcer




             2009 Atwood & Clark Consultants
    Negative Reinforcement
 Charging smokers higher insurance
  premiums
 Negative reinforcer is an event or
  behavior whose reinforcing properties
  are associated with its removal
     Example:   terminating an existing electric shock
     after a rat presses a bar is a negative reinforcer.


                 2009 Atwood & Clark Consultants
          Aversive/Punishment
 Use of electric shock as a punishing stimulus as is
  done in the Schick program to eliminate smoking
  behavior has had limited success
 In satiation treatment, subjects are required to
  increase the number of cigarettes smoked and the rate
  at which they are smoked
 Rapid smoking requires the subject inhale from a
  cigarette once every six seconds for the duration of
  the cigarette or until nauseated

                  2009 Atwood & Clark Consultants
              Punishment
 In addition to rewarding desirable behavior,
  behavior modification can also discourage
  unwanted behavior through punishment
 Punishment is the application of an aversive or
  unpleasant stimulus in reaction to a particular
  behavior
 Penalties
 Financial fines
 Extreme -- +education

                 2009 Atwood & Clark Consultants
          Extinction
 The removal of reinforcement altogether
  is called extinction
 Extinction eliminates the incentive for
  unwanted behavior by withholding the
  expected response




             2009 Atwood & Clark Consultants
Thank You


   2009 Atwood & Clark
       Consultants
Day 2: How To Quit

 Ata Ulhaq, MD, FACEP, MPH




         2009 Atwood & Clark
             Consultants
                4 Key Factors

 Making the decision to quit
 Setting a quit date and choosing a quit plan
 Dealing with withdrawal
 Staying quit (maintenance)




               2009 Atwood & Clark Consultants
       How Do People Change?

 Decision only individual can make




              2009 Atwood & Clark Consultants
             American Cancer Society


                Health Belief Model

   More likely to stop if you:
     Believe  you could get smoking related disease
      and this worries you
     Believe you can make an honest attempt

     Believe the benefits of quitting outweigh the
      benefits of continuing
     Know someone who has had health problems
      from smoking

                 2009 Atwood & Clark Consultants
            American Cancer Society


            Stages of Change

 Pre-contemplation
 Contemplation
 Preparation
 Action
 Maintenance



              2009 Atwood & Clark Consultants
     American Cancer Society


          Stages of Change
                   Precontemplation         Don’t want to quit



                     Contemplation          Want to quit sometime



                       Preparation          Will quit in next 30 days


                                            Am quitting now
                          Action


Relapse               Maintenance                Termination




          2009 Atwood & Clark Consultants
             American Cancer Society


              Preparing to Quit

 Pick a Quit Day, mark your calendar
 Plan for prescriptions (Zyban, Chantix)
 Tell friends and family about Quit Day




                2009 Atwood & Clark Consultants
             American Cancer Society


             Preparing to Quit

 Rid home, car and work of all ashtrays and
  cigarettes
 Stock up on oral substitutes (gum, carrot
  sticks, hard candy, toothpicks)
 Decide on a plan
 Set up support system (group, class, family,
  friend)

               2009 Atwood & Clark Consultants
               American Cancer Society


                    On Quit Day

   Do not smoke!                     Avoid situations that
   Keep active                        trigger urge to smoke
   Drink water, juices               Reduce or avoid
   Nicotine replacement               alcohol
   Attend class                      Change your routine




                  2009 Atwood & Clark Consultants
               American Cancer Society


                     Realizations

 Definition: mistaken thought that makes
  sense at the time, but is not based on reality
     I’ll just have one
     Today is not good, I’ll quit tomorrow
     It’s my only vice
     How bad is it, really?
     Air pollution is probably just as bad

                  2009 Atwood & Clark Consultants
               American Cancer Society


               Avoid Temptation

 Change your habits
     Alternatives: hard candy, coffee stirrer, etc.
     Activities: Exercise, needlework, woodworking
     Deep Breathing
     Delay: If you feel you are about to light up,
      delay



                  2009 Atwood & Clark Consultants
             American Cancer Society


       Get Through Tough Times

 Review reasons for quitting
 Think of benefits: health, finances, family
 There is no such thing as just one cigarette or
  just one puff
 Ride out the desire
 Avoid drinking alcohol
 Avoid weight gain by staying active

                2009 Atwood & Clark Consultants
               Atwood and Clark Consultants


                      Useful Tools

 Beck’s Depression Inventory
 Family and Personal Development Rating
  Scale (social history)
     These can help establish a percentage rating to
      determine “State of Readiness”




                    2009 Atwood & Clark Consultants
           American Lung Association


   Freedom From Smoking

 Highly structured comprehensive behavior
  modification approach to smoking cessation
  in a group support setting




              2009 Atwood & Clark Consultants
              American Lung Association


   Freedom From Smoking

 Based on premise that smoking is learned
  behavior
 Seven session format provides
     tracking personal habits
     developing coping strategies
     supportive environment with others who are
      experiencing the same feelings and challenges

                  2009 Atwood & Clark Consultants
               American Lung Association


           Thinking About Quitting
 Session 1:
     Three-Link Chain of Addition. Physical,
      mental and social aspects of addiction
     Benefits of Quitting. Physiological rewards
     Registration. Time to decide if ready
     Triggers and Coping. Prompts and effective
      ways to change behaviors
     Medications. Present medications

                   2009 Atwood & Clark Consultants
               American Lung Association


           On the Road to Freedom
 Session 2
     Self-Management. Techniques to help
      participants get past triggers
     Stress management. Discuss ways to
      counteract harmful feeling of stress
     Assessing Nicotine Dependence. Learn about
      personal nicotine addiction. Review
      medications that help smokers quit


                  2009 Atwood & Clark Consultants
               American Lung Association


                 Wanting to Quit
 Session 3
     Increasing Motivation. Reinforce “whys”
      behind quitting
     Social Support. Build a buddy system from
      within the group
     Making a Quit Plan. Design a plan to help
      succeed
     Relapse Prevention. Identify high-risk
      situations

                  2009 Atwood & Clark Consultants
                       American Lung Association


                                  Quit Day
 Session 4 (Follow up with Session 5 within 48 hours)
      Panel of Ex-Smokers. Listen to other’s personal experiences with
       quitting
      Quitting ceremony. A formal way to say goodbye to cigarettes
      Contracts and Rewards. Sign a 2-day contract not to smoke and
       list rewards
      Recovery Symptoms. Explain the physical and psychological
       symptoms of quitting smoking
      Overcoming Cravings. Special techniques to use when cravings
       come


                           2009 Atwood & Clark Consultants
                     American Lung Association


         Winning Strategies
 Session 5
     48-Hour Report. Assess short-term coping skills
     The Grief Cycle. Understand the physiological recovery from
      nicotine addition
     Benefits of Quitting. Discuss medical/non-medical benefits
     Coping Strategies. Review strategies for dealing with physical,
      mental and social aspects of quitting
     Refining the Quit Plan. Fine tune the original plan
     Stress Management. More exercises to improve relaxation


                         2009 Atwood & Clark Consultants
                 American Lung Association


                     The New You
 Session 6
     Progress Review. Assess participants’ success to date.
     Lifestyle changes. Ways to encourage lifetime abstinence.
     Weight Management. Introduce ways to control weight.
     Staying Smoke-Free. Overview of program and tips on
      long-term abstinence.
     Social Situations. Learn to handle risky social situations
      carefully.



                     2009 Atwood & Clark Consultants
                American Lung Association


                       Staying Off

 Session 7
     Physical Activity. A realistic approach to
      physical activity.
     Changing Your Self-Image. Become a non-
      smoker.
     Assertive Communication. Learn to
      communicate in ways that help to handle stress.


                    2009 Atwood & Clark Consultants
              American Lung Association


                   Celebration!
 Session 8
     Rewarding New Behaviors. Appreciate current
      success.
     Relapse Prevention. Continue with techniques
      that support not smoking.
     Challenge Your Thinking. Learn to think
      differently.
     Completion Ceremony. Recognize and celebrate
      completion of the program.

                 2009 Atwood & Clark Consultants
    Ultimate Goal – Complete Abstinence

 Even in instances when complete abstinence
  from smoking is not achieved, smoking
  cessation pharmacotherapies may benefit
  individual health - and ultimately the public’s
  health if the smoker reduces the number of
  cigarettes smoked.



               2009 Atwood & Clark Consultants
   Ultimate Goal – Complete Abstinence

 Relationship between cigarette smoking and
  lung cancer, and other smoking-associated
  malignancies, is strongly dose-dependent.
 Individual smoker who is unable or not
  motivated to quit may benefit by using
  pharmacotherapies (or other means) to
  reduce the number of cigarettes smoked per
  day.

              2009 Atwood & Clark Consultants
           Pharmacological Adjuncts

 Bupropion HCl is a non-nicotine aid to smoking
  cessation.
 Relatively weak inhibitor of the neuronal uptake
  of norepinephrine, serotonin, and dopamine, and
  does not inhibit monoamine oxidase.
 Exact mechanism by which bupropion HCl
  enhances ability of patients to abstain from
  smoking is unknown.
 Presumed that this action is mediated by
  noradrenergic or dopaminergic mechanisms.
                    2009 Atwood & Clark Consultants
        Theoretical Reasons Antidepressants
                       Help
 Two theoretical reasons to believe antidepressants
  might help in smoking cessation:
      Nicotine withdrawal may produce depressive symptoms or
       precipitate a major depressive episode and antidepressants
       may relieve these.
      Nicotine may have antidepressant effects that maintain
       smoking, and antidepressants may substitute for this effect.




                         2009 Atwood & Clark Consultants
        More on Antidepressants

 Alternatively, some antidepressants may
  have a specific effect on neural pathways
  underlying nicotine addiction, (e.g. blocking
  nicotine receptors) independent of their
  antidepressant effects.




               2009 Atwood & Clark Consultants
Questions?




 2009 Atwood & Clark
     Consultants
How To Quit

      Part 2




  2009 Atwood & Clark
      Consultants
                               Smokefree.gov




 Find reasons to quit that are important to you. Think
  of more than just health reasons. For example, think
  of:
      How much money you'll save by not buying cigarettes
      The time you'll have for yourself instead of taking
       cigarette breaks, rushing out to buy a pack, or searching
       for a light
      Not being short of breath or coughing as much
      Setting a better example for your children

                     2009 Atwood & Clark Consultants
                           Smokefree.gov


      Write Down Why You Want To Quit

 List ways to fight the urge to smoke, too.
  (You will find tips for coping later in this
  guide.)
 Keep your list where you'll see it often. Good
  places are:
     Where you keep your cigarettes
     In your wallet or purse
     In the kitchen
     In your car
                 2009 Atwood & Clark Consultants
                           Smokefree.gov


            Reasons for Quitting

1. I will feel healthier right away.
     I will have more energy and better focus.
     My senses of smell and taste will be better.
     I will have whiter teeth and fresher breath.
     I will cough less and breathe better.




                 2009 Atwood & Clark Consultants
                              Smokefree.gov


              Reasons for Quitting

2. I will be healthier the rest of my life.
      I will lower my risk for cancer, heart attacks, strokes,
       early death, cataracts, and skin wrinkling.
3. I will make my partner, friends, family, kids,
   grandchildren, and coworkers proud of me.
4. My children will be healthier (fewer ear
   infections, coughs, and severe asthma attacks).



                    2009 Atwood & Clark Consultants
                           Smokefree.gov


            Reasons for Quitting

5. I will be proud of myself.
     I will feel more in control of my life.
     I will be a better role model for my children.
6. I will have more money to spend.
7. I won't have to worry: "When will I get to
   smoke next?" or "What do I do when I'm in
   a smoke-free place?"

                 2009 Atwood & Clark Consultants
                           Smokefree.gov


       Overview of the Basic Steps

S = Set a quit date.
T = Tell family, friends, and coworkers that you
    plan to quit.
A = Anticipate and plan for the challenges you'll
    face while quitting.
R = Remove cigarettes and other tobacco products
    from your home, car, and work.
T = Talk to your doctor about getting help to quit.

                 2009 Atwood & Clark Consultants
                        Smokefree.gov


             Set a Quit Date

 Think about choosing a special day:
 Your birthday or wedding anniversary
 New Year's Day
 Independence Day
 World No Tobacco Day (May 31)
 The Great American Smokeout (the third
  Thursday of each November)

              2009 Atwood & Clark Consultants
                            Smokefree.gov


      Tell Others your Plan to Quit

 Ask everyone to understand your change in mood
 Remind them that this won't last long (The worst
  will be over within two weeks.)
 Tell them this: "The longer I go without cigarettes,
  the sooner I'll be my old self."
 Does someone close to you smoke? Ask them to
  quit with you, or at least not to smoke around you


                  2009 Atwood & Clark Consultants
                        Smokefree.gov


     Tell Others your Plan to Quit

 Do you take any medicines? Tell your doctor
  and pharmacist you are quitting.
 Nicotine changes how some drugs work. You
  may need to change your prescriptions after
  you quit.




              2009 Atwood & Clark Consultants
                         Smokefree.gov


     Tell Others your Plan to Quit

 Get support from other people. You can try
  talking with others one-on-one or in a group.
 You can also get support on the phone.
 You can even try an Internet chat room. This
  kind of support helps smokers quit.
 The more support you get, the better. But
  even a little can help.

               2009 Atwood & Clark Consultants
                              Smokefree.gov


      Benefits of a Quit-smoking Program

 Quit-smoking programs help smokers spot and cope
  with problems
 The programs teach problem-solving and other
  coping skills
 Can help you quit for good by:
     Helping you better understand why you smoke
     Teaching you how to handle withdrawal and stress
     Teaching you tips to help resist the urge to smoke


                    2009 Atwood & Clark Consultants
                        Smokefree.gov


                  Keep Busy

 Keep very busy today.
 Go to a movie.
 Exercise.
 Take long walks.
 Go bike riding



              2009 Atwood & Clark Consultants
                         Smokefree.gov


                   Keep Busy

 Spend as much free time as you can where
  smoking isn't allowed (malls, libraries,
  museums, theaters, department stores, and
  places of worship)
 Do you miss having a cigarette in your hand?
  Hold something else (a pencil, paper clip,
  marble)

               2009 Atwood & Clark Consultants
                         Smokefree.gov

         Stay Away from What
              Tempts You
 Instead of smoking after meals, get up from
  the table.
 Brush your teeth or go for a walk.




               2009 Atwood & Clark Consultants
                           Smokefree.gov

           Stay Away from What
                Tempts You
 If you always smoke while driving, try something
  new: Listen to a new radio station or your favorite
  music. Take a different route. Or take the train or
  bus for a while, if you can.
 Stay away from things that you connect with
  smoking. Do it today and for the next few weeks.
  These may include:
 Watching your favorite TV show

                 2009 Atwood & Clark Consultants
                           Smokefree.gov

           Stay Away from What
                Tempts You
 Sitting in your favorite chair
 Having a drink before dinner
 Do things and go places where smoking is not
  allowed. Keep this up until you're sure that you can
  stay smoke-free.
 Remember, most people don't smoke. Try to be
  near nonsmokers if you must be somewhere you'll
  be tempted to smoke, for example at a party or in a
  bar.

                 2009 Atwood & Clark Consultants
                        Smokefree.gov

         Remember the Instant
         Rewards of Quitting
 Your body begins to heal within 20 minutes
  after your last cigarette
 The poison gas and nicotine start to leave
  your body
 Your pulse rate goes back to normal
 The oxygen in your blood rises to a normal
  level

              2009 Atwood & Clark Consultants
                            Smokefree.gov

            Remember the Instant
            Rewards of Quitting
 Within a few days you may notice other
  things:
     Your senses of taste and smell are better.
     You can breathe easier.
     Your "smoker's hack" starts to go away. (You
      may keep coughing for a while, though.)



                  2009 Atwood & Clark Consultants
                         Smokefree.gov

          Remember the Instant
          Rewards of Quitting
 The nicotine leaves your body within three
  days. Your body starts to repair itself. At
  first, you may feel worse instead of better.
  Withdrawal feelings can be hard. But they
  are a sign that your body is healing.




               2009 Atwood & Clark Consultants
                               Smokefree.gov


       Long-term Rewards of Quitting

 After you've quit, you've added healthy, full days to
  each year of your life
 You've greatly lowered your risk of death from lung
  cancer and other diseases including:
      Heart disease
      Stroke
      Chronic bronchitis
      Emphysema
      At least 13 other kinds of cancer


                     2009 Atwood & Clark Consultants
    American Heart Association














         2009 Atwood & Clark Consultants
    American Heart Association


                Step One





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

         2009 Atwood & Clark Consultants
    American Heart Association


               Step Two





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         2009 Atwood & Clark Consultants
    American Heart Association


              Step Three


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



         2009 Atwood & Clark Consultants
    American Heart Association


               Step Four




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         2009 Atwood & Clark Consultants
    American Heart Association






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         2009 Atwood & Clark Consultants
    American Heart Association






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


         2009 Atwood & Clark Consultants
Questions?




 2009 Atwood & Clark
     Consultants
How To Quit

      Part 3




  2009 Atwood & Clark
      Consultants
      Nicotine Anonymous


    Nicotine Anonymous








     2009 Atwood & Clark Consultants
      Nicotine Anonymous


    Nicotine Anonymous









     2009 Atwood & Clark Consultants
                   Nicotine Anonymous


        Facing the Fatal Attraction

 Smoking tobacco is the most common method of
  nicotine delivery
 Worldwide 47.5% of men and 10.3% of women
  smoke a total of 6 trillion cigarettes a year (World
  Health Organization, 2008)




                  2009 Atwood & Clark Consultants
                   Nicotine Anonymous


        Facing the Fatal Attraction

 In 2000, 70% of U.S. adult smokers wanted to quit
 41% stopped smoking for at least one day during
  the preceding year in an effort to quit (Centers for
  Disease Control and Prevention)
 Since 1965, more than 49% of all adults who have
  ever smoked have quit




                  2009 Atwood & Clark Consultants
                Nicotine Anonymous

           The Twelve Steps of
           Nicotine Anonymous
1. We admitted we were powerless over nicotine –
   that our lives had become unmanageable.
2. Came to believe that a Power greater than
   ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives
   over to the care of God as we understood Him.




               2009 Atwood & Clark Consultants
                 Nicotine Anonymous

           The Twelve Steps of
           Nicotine Anonymous
4. Made a searching and fearless moral inventory of
   ourselves.
5. Admitted to God, to ourselves, and to another
   human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these
   defects of character.




                2009 Atwood & Clark Consultants
                Nicotine Anonymous

           The Twelve Steps of
           Nicotine Anonymous
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and
    became willing to make amends to them all.
9. Made direct amends to such people wherever
    possible, except when to do so would injure
    them or others.
10. Continued to take personal inventory and when
    we were wrong promptly admitted it.

               2009 Atwood & Clark Consultants
                  Nicotine Anonymous

            The Twelve Steps of
            Nicotine Anonymous
11. Sought through prayer and meditation to improve
    our conscious contact with God as we understood
    Him, praying only for knowledge of His will for
    us and the power to carry that out.
12. Having had a spiritual awakening as the result of
    these steps, we tried to carry this message to
    nicotine users and to practice these principles in
    all our affairs.


                 2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 It's not as hard as you think
 Inform yourself about nicotine
 Understand that you do not need nicotine (it
  is not nutritional)




               2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 Understand that addiction is a chemically
  compelled behavior
 Make an honest appraisal of your nicotine
  use
 Don't delay action toward stopping your use
  of nicotine because you think there are too
  many pressures in your life

               2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 Treat yourself with love and respect rather
  then by placating yourself with
  rationalizations
 Write down reasons why you want to be
  nicotine free rather than thinking about
  reasons why you "can't quit yet"


               2009 Atwood & Clark Consultants
                    Nicotine Anonymous


         Tips for Gaining Freedom

 Quit for yourself
 Look at quitting the use of nicotine as giving
  yourself a precious gift
 Make things easier for yourself
     Before quitting, plan your activities for the first
      few days of abstinence



                   2009 Atwood & Clark Consultants
                 Nicotine Anonymous


       Tips for Gaining Freedom

 Consider quitting as a challenging adventure
 Imagine letting go of nicotine
 There is no perfect time to start preparing to
  quit




                2009 Atwood & Clark Consultants
                 Nicotine Anonymous


       Tips for Gaining Freedom

 If you are not going to quit right away, try
  cutting down
 Don't minimize the truth or deny the risks
  even if you are not quitting today
 Set a quit date
 Look at quitting as an investment.


                2009 Atwood & Clark Consultants
                      Nicotine Anonymous


           Tips for Gaining Freedom

 Quit nicotine one day at time and think only about
  the part of the day you are in
 If you could have just one, you wouldn't have had
  the thousands of cigarettes you have smoked
      A pack a day for ten years is 73,000 cigarettes!
 Think about letting go of nicotine as a "choice"
  rather than something you are doing to deprive
  yourself
 Pray instead of puff

                     2009 Atwood & Clark Consultants
                      Nicotine Anonymous


           Tips for Gaining Freedom

 When you quit you may experience a sense of loss
 If you feel an urge to use nicotine think H.A.L.T.
      Four basic triggers for using nicotine are when we are
       Hungry, Angry, Lonely and Tired
 Feed your body with nutrition instead of nicotine
 Drink lots of liquids to help flush the poison out of
  your system
 What and how much you eat is important when you
  quit nicotine

                     2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 When you first stop, don't be surprised if you
  find yourself feeling cranky, grumpy, crabby
  or downright angry
 Take a second look before you react
 There are better companions than cigarettes
 Avoid becoming too tired


               2009 Atwood & Clark Consultants
                  Nicotine Anonymous


        Tips for Gaining Freedom

 Sometimes all we need is a distraction to shift our
  focus from a craving
 Surround yourself with supportive positive people
 Ask for help from family, friends, and co-workers
 Plan activities that do not permit tobacco use
 Keep something handy for your hands



                 2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 Boredom is a signal to get busy
 Suck, bite, or chew
 Change your routine




               2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 Give yourself rewards, frequently
 Avoid the self-pity trap
 If you have a problem and then use nicotine,
  you now have two problems
 Re-read all the Nicotine Anonymous
  literature on a regular basis


               2009 Atwood & Clark Consultants
                Nicotine Anonymous


       Tips for Gaining Freedom

 All you have to do is not have the "next one"
  and you will avoid smoking thousands
 Frequently notice how you are improving
 Maintain what you have gained
 If you want to smoke, use all the tools of the
  program instead, and Keep Showing Up


               2009 Atwood & Clark Consultants
        hhs.gov

 Tobacco dependence is a chronic disease that often
  requires repeated intervention and multiple attempts
  to quit
 Effective treatments exist, however, that can
  significantly increase rates of long-term abstinence
 It is essential that clinicians and healthcare delivery
  systems consistently identify and document tobacco
  use status and treat every tobacco user seen in a
  healthcare setting

                  2009 Atwood & Clark Consultants
      hhs.gov

 Tobacco dependence treatments are
  effective across a broad range of
  populations
 Clinicians should encourage every patient
  willing to make a quit attempt to use the
  recommended counseling treatments and
  medications in the Guideline

              2009 Atwood & Clark Consultants
      hhs.gov

 Brief tobacco dependence treatment is
  effective
 Clinicians should offer every patient who
  uses tobacco at least the brief treatments
  shown to be effective in the Guideline




               2009 Atwood & Clark Consultants
           hhs.gov

       Individual, group and telephone counseling are
        effective and their effectiveness increases with
        treatment intensity
       Two components of counseling are especially
        effective and clinicians should use these when
        counseling patients making a quit attempt:
         Practical counseling (problem-solving/skills training)
         Social support delivered as part of treatment


                      2009 Atwood & Clark Consultants
                                          hhs.gov


        FDA Approved Medications

 Seven first-line medications (5 nicotine and 2 non-
  nicotine) reliably increase long-term smoking
  abstinence rates:
      Bupropion SR
      Nicotine gum
      Nicotine inhaler
      Nicotine lozenge
      Nicotine nasal spray
      Nicotine patch
      Varenicline
                     2009 Atwood & Clark Consultants
       hhs.gov

   Counseling and medication are effective when
    used by themselves for treating tobacco
    dependence
   The combination of counseling and medication is
    more effective than either alone
   Thus, clinicians should encourage all individuals
    making a quit attempt to use both counseling and
    medication

                 2009 Atwood & Clark Consultants
       hhs.gov

   Telephone quitline counseling is effective with
    diverse populations and has broad reach
   Clinicians and healthcare delivery systems should
    both ensure patient access to quitlines and
    promote quitline use
   If a tobacco user is currently unwilling to make a
    quit attempt, clinicians should use the
    motivational treatments shown in the Guideline to
    be effective in increasing future quit attempts

                 2009 Atwood & Clark Consultants
       hhs.gov

 Tobacco dependence treatments are both clinically
  effective and highly cost-effective relative to
  interventions for other clinical disorders
 Providing coverage for these treatments increases
  quit rates
 Insurers and purchasers should ensure that all
  insurance plans include the counseling and
  medication identified as effective in the Guideline
  as covered benefits

                 2009 Atwood & Clark Consultants
    Questions?




2009 Atwood & Clark Consultants
How To Quit

      Part 4




  2009 Atwood & Clark
      Consultants
                         Surgeon General

        "5 A's" Model for Treating
       Tobacco Use and Dependence
1. Ask about tobacco use
  a)   Identify and document tobacco use status of
       every patient at every visit
2. Advise to quit
  a)   In a clear, strong and personalized manner urge
       every tobacco user to quit



                 2009 Atwood & Clark Consultants
                         Surgeon General


                  "5 A's" Model

3. Assess
  a)   For current tobacco user, is the tobacco user
       willing to make a quit attempt at this time?
  b)   For the ex-tobacco user, how recent did you
       quit and are there any challenges to remaining
       abstinent?




                 2009 Atwood & Clark Consultants
                           Surgeon General


                   "5 A's" Model
4. Assist
  a)   For the patient willing to make a quit attempt,
       offer medication and provide or refer for
       counseling or additional behavioral treatment to
       help the patient quit
  b)   For patients unwilling to quit at this time,
       provide motivational interventions designed to
       increase future quit attempts
  c)   For the recent quitter and any with remaining
       challenges, provide relapse prevention
                   2009 Atwood & Clark Consultants
                         Surgeon General


                  "5 A's" Model

5. Arrange
  a)   All those receiving the previous A's should
       receive follow up




                 2009 Atwood & Clark Consultants
                          Surgeon General

        Advise—Strongly Urge All
          Tobacco Users to Quit
 Action
     In a clear, strong, and personalized manner, urge
      every tobacco user to quit
 Advice should be:
     Clear—"I think it is important for you to quit
      smoking (or using chewing tobacco) now and I
      can help you."
     "Cutting down while you are ill is not enough."
     “Occasional or light smoking is still dangerous.”
                  2009 Atwood & Clark Consultants
                       Surgeon General


            Advice Should Be

 Strong—"As your clinician, I need you to
  know that quitting smoking is the most
  important thing you can do to protect your
  health now and in the future.
 The clinic staff and I will help you."




               2009 Atwood & Clark Consultants
                          Surgeon General


               Advice Should Be
 Personalized
     Tie tobacco use to current symptoms and health
      concerns, and/or its social and economic costs.
     and/or the impact of tobacco use on children and
      others in the household.
     “Continuing to smoke makes your asthma worse,
      and quitting may dramatically improve your
      health.
     Quitting smoking may reduce the number of ear
      infections your child has.”
                  2009 Atwood & Clark Consultants
               Public Health Service

     Public Health Service (PHS)
              Guideline
 Ensure that all smokers are offered
  effective tobacco-use treatment at all
  clinical encounters.
 Increase access to and participation in
  effective tobacco-use counseling.



              2009 Atwood & Clark Consultants
               Public Health Service

     Public Health Service (PHS)
              Guideline
 Increase access to and appropriate use
  of effective tobacco-treatment
  medications.
 Reduce patient out-of-pocket costs for
  tobacco-use treatment.
 Create a social and economic
  environment that promotes quitting

              2009 Atwood & Clark Consultants
                Public Health Service


    Community Preventive Services

 Increase the unit price for tobacco
  products
 Implement sustained mass media
  campaigns




               2009 Atwood & Clark Consultants
                Public Health Service


    Community Preventive Services

 Implement provider reminder systems in
  health-care settings
 Reduce patient out-of-pocket costs for
  tobacco-use treatment
 Initiate multi-component interventions
  that include patient telephone


               2009 Atwood & Clark Consultants
                           CDC


                 CDC Goals


 Mobilize health insurers, employers, and
  others to foster evidence-based tobacco-
  dependence coverage for all covered
  lives.
 Mobilize health systems to implement
  system-level changes to foster effective
  utilization of tobacco-dependence
  treatments. 2009 Atwood & Clark Consultants
                                       CDC


                  CDC Goals

 Mobilize national quality assurance and
  accreditation organizations, clinicians,
  health systems, and others to establish
  and measure the treatment of tobacco
  dependence as part of the standard of
  care (www.cdc.gov/tobacco/ICHS).



              2009 Atwood & Clark Consultants
                                      CDC


                 CDC Goals

 Mobilize communities to ensure that
  policies and programs are in place to
  increase demand for services and to
  ensure access to such services,
  especially for underserved populations
  (Fiore et al., 2004).



             2009 Atwood & Clark Consultants
                                         CDC


               CDC Strategies


 Health insurance that pays the full cost of
  smoking-cessation treatments can increase
  quit rates compared to benefit plans that only
  partially cover cessation treatment or that offer
  no cessation benefits
 Programs to stop smoking delivered during
  hospitalization that include a 1-month follow-up
  are most effective

                2009 Atwood & Clark Consultants
                                       CDC


             CDC Strategies

 Proactive telephone counseling can be
  effective compared to an intervention
  without personal contact
 Successful interventions generally
  involve multiple contacts timed around a
  quit attempt


              2009 Atwood & Clark Consultants
                                         CDC


               CDC Strategies

 All of the commercially available forms of
  nicotine replacement therapy (gum,
  transdermal patch, nasal spray, inhaler, and
  sublingual tablets/ lozenges) are effective as
  part of a strategy to promote smoking
  cessation
 Standard self-help materials may increase quit
  rates compared to no intervention, but the
  effect is likely to be small
                2009 Atwood & Clark Consultants
            Negative Incentives

 Focus on the failure of an individual to adopt
  a desired behavior
 Discipline the individual by withdrawing the
  reward
 Believing this will encourage adoption of the
  desired behavior


               2009 Atwood & Clark Consultants
           Negative Incentives

 The 192 members of WHO unanimously
  adopted the Framework Convention on
  Tobacco Control (FCTC)
 Aimed at curbing tobacco-related deaths and
  disease




              2009 Atwood & Clark Consultants
         WHO Negative Incentives

 requires countries to impose restrictions on:
     tobacco advertising
     sponsorship and promotion
     establish new labeling
     clean indoor air controls
     strengthen legislation to clamp down on tobacco
      smuggling


                  2009 Atwood & Clark Consultants
           Negative Incentives

 Taiwan doubled the surcharge on cigarettes
  to discourage smoking
 US: on April 1, 2009, the tax on cigarettes
  rose from 39 cents to $1.01 per pack




               2009 Atwood & Clark Consultants
           Negative Incentives

 Chile bans smoking in schools, hospitals,
  government offices, shopping centers,
  supermarkets, pharmacies, airports, buses,
  subway networks and other indoor public
  places. Smoking in universities indoors is
  banned, however, smoking is allowed
  outdoors.

               2009 Atwood & Clark Consultants
           Negative Incentives

 Croatian Parliament passed legislation
  prohibiting smoking in public institutions
  such as hospitals, clinics, schools and
  universities with infractions punishable with
  up to 1000 kuna (140 euros).
 A notable exception in the Act are
  psychiatric wards in Croatia's hospitals.

               2009 Atwood & Clark Consultants
              On the Flip Side…

 The Gong’an County government of Hubei
  province found itself at the center of public outrage
 Demanded local officials to consume up to 23,000
  packs of locally produced cigarettes annually, worth
  4 million yuan, using public money
 Each office under its jurisdiction received a quota
  and would face a fine if they failed to meet the
  target, or if found buying cigarettes produced by
  other provinces

                 2009 Atwood & Clark Consultants
                Of Interest…

 www.stickK.com
 take out a
  “commitment contract”
 By doing so, you
  essentially put your
  money where your
  mouth is


               2009 Atwood & Clark Consultants
           More on StickK.com

 You commit yourself to quit smoking within a
  month
 If at the end of the month, you’re still smoking,
  Stickk will keep the money you deposited
 To make it even more interesting, whenever
  you fail, they have the option of giving your
  money away to a cause (or person) you really
  hate.

                2009 Atwood & Clark Consultants
    Put Your Money Where Your
              Butt Is
 CARES (Committed Action to Reduce and
  End Smoking) is a commitment savings
  program
 Smokers who wish to quit smoking are
  encouraged to deposit an increasing
  percentage of the money they ordinarily
  spend on cigarettes into their CARES
  accounts for six months

             2009 Atwood & Clark Consultants
    Put Your Money Where Your
              Butt Is
 Deposits are collected every week by field
  staff who motivate clients to continue
  reducing smoking behavior
 The client cannot withdraw any money
  during the deposit period




              2009 Atwood & Clark Consultants
     Put Your Money Where Your
               Butt Is
 The balance is what is at stake if the client should
  fail to quit
 At the end of six months, the client submits to a
  urine test to confirm smoking cessation
 Only by passing the test can s/he access the money
  in the CARES account
 Otherwise, the account is closed and the money
  donated to a charity

                 2009 Atwood & Clark Consultants
            Positive Incentives

 Providing smokers with financial incentives
  to stop smoking increases enrollment in
  smoking-cessation programs
 Cessation efforts using monetary incentives
  have had yielded increased success in
  abstinence
 Receive incentives or prizes for “good”
  behavior – in this case, not smoking

               2009 Atwood & Clark Consultants
           Example of Positive
            Incentive Program
 Individuals given chance to win prizes if
  their breath and urine samples test negative
  for cigarette smoking.
 The number of draws from a prize bowl
  increases as long as the participant continues
  to test negative over the 24-week study


               2009 Atwood & Clark Consultants
                    Positive
               Incentive Program
 The prize bowl contains about 500 cards, half of
  which are winning cards.
 Prizes range from small toiletries, snacks, or coffee
  shop gift certificates, to tool kits, compact disc
  players, and prepaid telephone cards.
 One card in the prize bowl offers a $100 prize such
  as a DVD player, a television, or a stereo.
 The cards are replaced after each drawing so the
  probabilities remain constant.

                  2009 Atwood & Clark Consultants
    Questions?




2009 Atwood & Clark Consultants
Day 3: Proposed Program

   Ata Ulhaq, MD, FACEP, MPH




           2009 Atwood & Clark
               Consultants
                 3 Year Program

 Phase 1: Year 1
     University can become flag bearer/pioneer in
      beginning a program for other universities, cities
      and the entire country
     Program for students, faculty, contractors
      (anyone who is on property)
     Positive reinforcement with help and rewards


                  2009 Atwood & Clark Consultants
                3 Year Program

 Phase 1: Year 1
     Four week program open for 3 years and beyond
     Specific brochure/booklet for new students
      advising them of smoke free plan
     Heavy promotion should be done




                 2009 Atwood & Clark Consultants
         Government Involvement

 Support encouraged by governmental
  organizations
 Involvement in public awareness
     Radio ads
     TV ads
     Billboards
     Public service announcements

                 2009 Atwood & Clark Consultants
            University Involvement

 Signs on campus
 College radio station
 Publication
 Full support of student body/student union
 Visible student involvement
     Joining and supporting – not just talk
     Actively involved on an individual basis
                   2009 Atwood & Clark Consultants
                    3 Year Program

 Phase 1: Year 1
      Funding from University, government, other agencies
      Support by faculty, student union/student body, all
       involved in campus
      Step wise reduction/cessation
      Set up restricted smoking areas
      New students are advised that in three years, campus will
       be totally smoke-free
      Smokers are strongly advised to join program

                     2009 Atwood & Clark Consultants
                 3 Year Program

 Phase 2: Year 2
     Continue 1st year program
     Controlled, organized continuation of 4-week
      program
     Mostly negative incentives
     Demand smoking to restricted smoking areas
      only


                  2009 Atwood & Clark Consultants
                    3 Year Program

 Phase 2: Year 2
     If found smoking in other than designated areas,
      impose fines
         Monetary, temporary privileges
     At the end of Phase 2, remove restricted areas
     Anonymous reporting system for non-
      compliance comprised of student body (optional)


                     2009 Atwood & Clark Consultants
                3 Year Program
 Phase 3: Year 3
     Continuation of Phases 1 and 2
     No smoking
     Increased negative incentives
     Increased penalties (monetary)
     Prospective students who are smokers must join
      Program before enrolling in University
     Students are required to join program for non-
      compliance
                 2009 Atwood & Clark Consultants
                     3 Year Program

 Phase 3: Year 3
     Expulsion/no admittance for smokers
     Anonymous reporting system for non-
      compliance comprised of student body (optional)
         In class, student union, dormitories, etc.
     If penalties are not paid, registration for next
      semester could be withheld
     Once penalized, they must join 4-week program


                      2009 Atwood & Clark Consultants
               3 Year Program

 Faculty follows same rules and regulations as
  student body
 Separate session for faculty
 Faculty offered the 4-week program




               2009 Atwood & Clark Consultants
                  3 Year Program
 Penalties vary
     Increased monetary value for faculty (double that
      of students)
     Possibly more for repeat offense of non-
      compliance
     Reporting of non-compliance by faculty and
      students
     Once penalized, they must join 4-week program

                  2009 Atwood & Clark Consultants
                 3 Year Program

 Contractors
     Follows same regulations
     Worst penalty – they can lose their contract
     Can they join the program?
       Separate session for contractors only
       Contractors must pay fee to join program

       Once penalized, they must join 4-week program




                  2009 Atwood & Clark Consultants
              Year 1: Phase 1

 Beginning program kickoff
 Supportive of individuals who want to quit




               2009 Atwood & Clark Consultants
                        Kickoff

 Set day in advance and build up towards it
 Well publicized and well known
 When big day arrives, make it a big event!
 Celebration!




               2009 Atwood & Clark Consultants
        Principle


   “A Healthy
  Body Resides
a Healthy Mind”


 2009 Atwood & Clark Consultants
               Before Beginning
 Registration
 Screening to determine motivation
     What made them come?
 Based on motivation, grade is given
     + 75% will succeed in quitting (if life value
          involvement is present/doing it for their
      children)
     + - 50% possibility of quitting
     - 75% will not quit
                  2009 Atwood & Clark Consultants
               Who Gets + 75%?

     Those who have life value involvement


 Who gets + - 50%?
     Those you are not sure of
 Who gets – 75%?
     Those who do not have life value involvement or
      are doing it for someone other than themselves

                  2009 Atwood & Clark Consultants
       Life Value Involvement

 Belief you could get smoking related
  disease and this worries you
 Someone close who has had health
  problems from smoking; cancer
 Loved one died
 Heart attack (self or loved one)

             2009 Atwood & Clark Consultants
        Life Value Involvement

 Belief and motivation that is self-
  centered/tragic experience = more likely
  to quit




             2009 Atwood & Clark Consultants
                       Screening

 Physical screening +        -      (optional)
 Determine underlying medical condition
 Individual who has coughed blood
 Other bleeding (hematuria, melena or
  hematochezia, hematemesis)
 Weight loss/unable to gain weight – weakness
 These should be referred for further evaluation


                 2009 Atwood & Clark Consultants
                         Depression

 Depression is associated with an increased
  frequency of smoking
 Addicted smokers are characterized by:
      preoccupation with smoking
      abnormal attachment to cigarettes
      anticipation of brain reward
 Attempts to quit smoking often lead to a decreased
  level of pleasure and undesirable mood swings

                     2009 Atwood & Clark Consultants
     Beck’s Depression Inventory

 Created by Dr. Aaron T. Beck
 21-question multiple-choice self-report
  inventory
 One of the most widely used instruments for
  measuring the severity of depression



               2009 Atwood & Clark Consultants
             Reason for Beck’s?

 Individuals with underlying or current depressive
  symptoms are more likely to experience mood
  disturbances when they attempt to quit
 Smoking may mask an underlying depression in
  some smokers
 Smoking, therefore, may be a way for depressed
  individuals to self-medicate depressive symptoms


                 2009 Atwood & Clark Consultants
           Reason for Beck’s?

 Consequently, healthcare professionals who
  offer smoking cessation programs should
  offer depression screening
 Should be prepared to address underlying
  mood disorders as part of a comprehensive
  smoking cessation program


              2009 Atwood & Clark Consultants
      Beck’s Depression Inventory

1. SADNESS
    (feeling or showing sorrow; unhappy;
    causing or characterized by sorrow or
    regret; unfortunate and regrettable)
  0   I do not feel sad.
  1   I feel sad much of the time.
  2   I'm sad all the time.
  3   I'm so sad and unhappy that I can't sand it.

                 2009 Atwood & Clark Consultants
                              BDI

2. PESSIMISM
  0   I'm not discouraged about my future.
  1   I feel more discouraged about my future than I
      used to be.
  2   I do not expect things to work out for me.
  3   I feel my future is hopeless and will only get
      worse.


                2009 Atwood & Clark Consultants
                               BDI

3. PAST FAILURE
  0   I do not feel like a failure.
  1   I have failed more than I should have.
  2   As I look back, I see a lot of failures.
  3   I feel I am a total failure as a person.




                 2009 Atwood & Clark Consultants
                              BDI

4. LOSS OF PLEASURE
 0   I get as much pleasure as I ever did from the
     things I enjoy.
 1   I don't enjoy things as much as I used to.
 2   I get very little pleasure from the things I used
     to enjoy it.
 3   I can't get any pleasure from the things I used
     to enjoy.


                2009 Atwood & Clark Consultants
                             BDI

5. GUILTY FEELINGS
 0   I don't feel particularly guilty.
 1   I feel guilty over many things I have done or
     should have done.
 2   I feel quite guilty most of the time.
 3   I feel guilty all of the time.



               2009 Atwood & Clark Consultants
                              BDI

6. PUNISHMENT FEELINGS
 0   I don't feel I am being punished.
 1   I feel I may be punished.
 2   I expect to be punished.
 3   I feel I am being punished.




                2009 Atwood & Clark Consultants
                               BDI

7. SELF-DISLIKE
  0   I feel the same about myself as ever.
  1   I have lost confidence in myself.
  2   I am disappointed in myself.
  3   I dislike myself.




                 2009 Atwood & Clark Consultants
                              BDI

8. SELF-CRITICALNESS
 0   I don't criticize or blame myself more than
     usual.
 1   I am more critical of myself than I used to be.
 2   I criticize myself for all of my faults.
 3   I blame myself for everything bad that
     happens.


                2009 Atwood & Clark Consultants
                             BDI

9. SUICIDAL THOUGHTS OR WISHES
 0   I don't have any thoughts of killing myself.
 1   I have thoughts of killing myself, but I would
     not carry them out.
 2   I would like to kill myself.
 3   I would kill myself if I had the chance.



               2009 Atwood & Clark Consultants
                               BDI

10. CRYING
  0   I don't cry anymore than I used to.
  1   I cry more than I used to.
  2   I cry over every little things.
  3   I feel like crying, but I can't.




                 2009 Atwood & Clark Consultants
                                   BDI

11. AGITATION
    (a stirring up or arousing; disturbance of
    tranquility; disturbance of mind which shows itself
    by physical excitement)
   0   I am no more restless or wound up than usual.
   1   I feel more restless or wound up than usual.
   2   I am so restless or agitated that it's hard to stay still.
   3   I am so restless or agitated that I have to keep moving
       or doing something.

                     2009 Atwood & Clark Consultants
                               BDI

12. LOSS OF INTEREST
  0   I have not lost interest in other people or
      activities.
  1   I am less interested in other people or things
      than before.
  2   I have lost most of my interest in other people
      or things.
  3   It's hard to get interested in anything.


                 2009 Atwood & Clark Consultants
                                  BDI

13. INDECISIVENESS
    (not having or showing the ability to make
    decisions quickly and effectively)
   0   I make decisions about as well as ever.
   1   I find it more difficult to make decisions than usual.
   2   I have much greater difficulty making decisions than I
       used to.
   3   I have trouble making any decisions.


                    2009 Atwood & Clark Consultants
                                  BDI

14. WORTHLESSNESS
    (having no real value or use; having no good
    qualities; deserving contempt)
   0   I do not feel I am worthless.
   1   I don't consider myself as worthwhile and useful as I
       used to.
   2   I feel more worthless as compared to other people.
   3   I feel utterly worthless.


                    2009 Atwood & Clark Consultants
                             BDI

15. LOSS OF ENERGY
 0   I have as much energy as ever.
 1   I have less energy than I used to have.
 2   I don't have enough energy to do very much.
 3   I don't have enough energy to do anything.




               2009 Atwood & Clark Consultants
                                 BDI

16. CHANGES IN SLEEPING PATTERN
    (Changes in either direction are important. Thus
    tick the appropriate answer either less or more do
    you sleep.)
   0   I have not experienced any change in my sleeping
       pattern.
   1   I sleep somewhat more OR less than usual.
   2   I sleep a lot more OR less than usual.
   3   I sleep most the day. OR I wake up 1-2 hours early and
       can't get back to sleep.

                   2009 Atwood & Clark Consultants
                              BDI

17. IRRITABLITY
    (having or showing a tendency to be easily
    annoyed or made angry)
  0   I am no more irritable than usual.
  1   I am more irritable than usual.
  2   I am much more irritable than usual.
  3   I am irritable all the time.

                2009 Atwood & Clark Consultants
                                  BDI

18. CHANGES IN APPETITE
    (Changes in either direction are important. Thus
    tick the appropriate answer either less or more do
    you eat.)
   0   I have not experienced any change in my appetite.
   1   My appetite is somewhat less than usual. OR My
       appetite is somewhat greater than usual.
   2   My appetite is much less than usual. OR My appetite is
       much greater than usual.
   3   I have no appetite at all. OR I crave food all the time.

                    2009 Atwood & Clark Consultants
                               BDI

19. CONCENTRATION DIFFICULTY
    (the action or power of focusing one's
    attention or mental effort)
  0   I can concentrate as well as ever.
  1   I can't concentrate as well as usual.
  2   It's hard to keep my mind on anything for long.
  3   I find I can't concentrate on anything.

                 2009 Atwood & Clark Consultants
                              BDI

20. TIREDNESS OR FATIGUE
 0   I am no more tired or fatigued than usual.
 1   I am more tired or fatigued more easily than
     usual.
 2   I am too tired or fatigued to do a lot of things I
     used to to do.
 3   I am too tired or fatigued to do most of the
     things I used to to do.


                2009 Atwood & Clark Consultants
                               BDI

21. LOSS OF INTEREST IN
    RELATIONSHIPS
  0   I have not noticed any recent change in my
      interest in relationships.
  1   I am less interested in relationships than I used
      to be.
  2   I am much less interested in relationships now.
  3   I have lost interest in relationships completely.

                 2009 Atwood & Clark Consultants
           Scoring of Beck’s
          Depression Inventory
 Total score of 0-13 is considered minimal
  range
 14-19 is mild
 20-28 is moderate
 29-63 is severe



               2009 Atwood & Clark Consultants
           Treatment for Smoking
          Addiction and Depression
 New medicine treatment for smoking addiction that
  is also an effective antidepressant
      Bupropion, (Zyban) is a safe and effective
      Non-nicotine treatment
      Lessens withdrawal symptoms
      Prevents weight gain
      Improves mood in most patients
      Before Zyban™ was approved for smoking cessation, it
       was, and remains, an effective and commonly prescribed
       antidepressant sold under the trade name Wellbutrin™.

                    2009 Atwood & Clark Consultants
                  Other Treatments

 Seven first-line medications (5 nicotine and 2 non-
  nicotine) reliably increase long-term smoking
  abstinence rates:
      Nicotine gum
      Nicotine inhaler
      Nicotine lozenge
      Nicotine nasal spray
      Nicotine patch
      Varenicline


                     2009 Atwood & Clark Consultants
                   Makes Sense

 The Author notes that if no depression is
  present, it is reasonable to treat nicotine with
  nicotine
     Nicotine patch
     Gum
     Inhalant



                  2009 Atwood & Clark Consultants
           Proposed Program

 Smokefree.gov
 American Heart Association
 American Lung Society

         Organized 4-week program



              2009 Atwood & Clark Consultants
                           Smokefree.gov


       Overview of the Basic Steps

S = Set a quit date.
T = Tell family, friends, and coworkers that you
    plan to quit.
A = Anticipate and plan for the challenges you'll
    face while quitting.
R = Remove cigarettes and other tobacco products
    from your home, car, and work.
T = Talk to your doctor about getting help to quit.

                 2009 Atwood & Clark Consultants
Products to Help




 2009 Atwood & Clark Consultants
                                Week 1

 Facilitator will help by presenting ill effects of
  cigarette smoking
 Program should run 2-3 hours for week 1
 Have support group in place
         Female support for females/male support for males
 Write down list of reasons for quitting on an index
  card
 Make several (you can even laminate)

                       2009 Atwood & Clark Consultants
                 List of Reasons

 Put these lists in places where you frequently
  smoke
     Car, purse, wallet, office, fridge
     Tuck one in your books as a bookmark
     Wrap one around your cigarette pack with a
      rubber band



                  2009 Atwood & Clark Consultants
                          Rewards

 Reward yourself at the end of each nonsmoking
  week
 Write reward on back of list of reasons to quit
 Doesn’t have to be expensive
      Homemade meal
      Hot bath
 When the urge comes, look at both sides of the card
 Isn’t it worth coping for 3 minutes?

                  2009 Atwood & Clark Consultants
   When the Urge to Smoke Arises

 Remind yourself of why you quit by reading
  the list!
 Place a sticker on the back for each time you
  resist




               2009 Atwood & Clark Consultants
                        Week 2

 Set a quit day
 Talk to your doctor/obtain prescription
 Tell family, friends, co-workers
 Anticipate changes
 Remove cigarettes, ashtrays, etc.



               2009 Atwood & Clark Consultants
                  Week 2 Plans
      Have Alternate Plans in Case You are Tempted

 Get away from dinner                 Wash the car
  table                                Knit a scarf
 Go for a walk                        Garden
 Exercise                             Read a book
 Call a friend                        Take up a new hobby
 Listen to music or talk              Brush/floss your teeth
  radio in the car
             Anything to avoid smoking!
                 2009 Atwood & Clark Consultants
                   Week 2 Plans

 Be Prepared for Your Urges!
 In most cases, something triggers the craving
     Certain feelings
     People
     Places




                  2009 Atwood & Clark Consultants
                  Week 2 Plans

 Be Prepared for Your Urges!
 Divide a blank piece of paper into 2 columns
 On one side list “triggers”
     Stuck in traffic
     Morning coffee
     Arguing with colleague
 In column 2 write alternative course of action
                 2009 Atwood & Clark Consultants
            Week 2 Plans
     Alternative Course of Action
        Trigger                            Action
                                   Read morning paper
 Morning coffee

 Heated argument                  Walk around the block
                                                 or
                                   Write down everything you
                                    think about this person and
                                    then tear it up and throw it
                                    away
                                    (this works!)
               2009 Atwood & Clark Consultants
         Triggers and Alternatives

 If riding in the car, make your car an
  unfriendly place to smoke
     Clean it out
     Empty and scrub the ashtrays and the glove
      compartment




                  2009 Atwood & Clark Consultants
           Triggers and Alternatives

 Do you find yourself wanting a cigarette right after
  eating?
      Get busy immediately after your meal
      Get up and clear the table
      Do the dishes/pack up the leftovers
 Often just getting through the first few minutes is
  all you need
 Just delay that urge

                    2009 Atwood & Clark Consultants
                Week 2 Plans:
               Distract Yourself
 With a quick task (5-10 minutes)
     Make a call
     Send a fax
     Pour yourself a cup of coffee
     Water a plant
     Anything!
     Hint: Find something that makes smoking
      impossible

                 2009 Atwood & Clark Consultants
               Week 2 Plans:
               Remember…
S = Set a quit date.
T = Tell family, friends, and coworkers that you
plan to quit.
A = Anticipate and plan for the challenges you'll
     face while quitting.
R = Remove cigarettes and other tobacco products
     from your home, car, and work.
T = Talk to your doctor about getting help to quit.


               2009 Atwood & Clark Consultants
                     Week 3 A

                      Quit day!
 Keep busy!
 Utilize support group already in place
 Remember coping mechanisms




               2009 Atwood & Clark Consultants
                     Week 3 A

 Remember list, read and re-read
 Do things that make you happy
 Get involved in other activities
 Keep away from people, places, things that
  remind you of smoking



               2009 Atwood & Clark Consultants
                Author’s Note

 Plan to quit at least one day before using any
  drugs or nicotine aids
 Drugs or nicotine aids more effective when
  used in this manner




               2009 Atwood & Clark Consultants
                         Week 3 B

 Two days after quit day:
     This is most difficult time
     Bring individual in again to reinforce
     Should be seen a total of 5 times
     See how they are tolerating things
     Check their list for dots indicating they resisted
      the urge to smoke


                   2009 Atwood & Clark Consultants
                              Week 4
 Successfully complete one week smoke free
 Re-evaluate support group’s efforts
 Support group to involve facilitator
       Female support for females/male support for males
 Not more than 20 people
  for each facilitator


                     2009 Atwood & Clark Consultants
                           Week 4

 Compliment and encourage each other
 Group to be available 24/7 by phone
 Female support for females/male support for
  males
 Meet weekly for two months
     Once monthly thereafter
     Support as long as individuals desire
     Open for alumni as well
                  2009 Atwood & Clark Consultants
                 Phase 2: Year 2

 Ongoing 4-week program
 Restricted areas are now removed
 Fines are imposed on smokers
     Monetary
     Other privileges temporarily withheld




                  2009 Atwood & Clark Consultants
              Phase 3: Year 3

 Penalties/fines increase
 Program readily available
 Increased negative incentives
 Prospective students who are smokers must
  join Program before enrolling in University
 Expulsion/no admittance for smokers


               2009 Atwood & Clark Consultants
Questions? Comments?




   2009 Atwood & Clark Consultants
          Day 4: Open Forum

 Participants will join for an open forum and
  discussion concerning modification of the
  proposed program or accepting it as such for
  the University.




               2009 Atwood & Clark Consultants
      Day 5: Formulation of a
    Program for The University
 Participants will unite to give their blessing
  to the accepted program for the University
 University now becomes the flag
  bearer/pioneer in beginning a program for
  other universities, cities and the entire
  country


                2009 Atwood & Clark Consultants
Thank You


   2009 Atwood & Clark
       Consultants

				
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