Professional Documents
Culture Documents
Introduction
Who are you ? Where are you from ? What do you want to get from this workshop?
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Aim of training
To increase your knowledge, skills and confidence; to equip you to provide training on brief tobacco interventions, intensive counselling and nicotine replacement therapy (NRT).
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Objectives
1. Describe prevalence and patterns of tobacco use in Ghana 2. Explain the role of tobacco dependence treatment within a comprehensive tobacco control strategy 3. Explain the health consequence of tobacco use and benefits of quitting 4. Explain the biological, psycho-behavioural and social causes of tobacco dependence 5. Identify evidence-based tobacco dependence treatments 6. Describe and deliver brief interventions as part of their routine practice according to a "5A's" Model and a "5R's" Model 7. Demonstrate effective counselling skills (motivational interviewing, practical counselling) 8. Conduct a brief assessment of nicotine dependence 9. Understand and appropriately prescribe Nicotine Replacement Therapy products 10. Describe strategies and coping skills that can reduce relapse risk 11. Describe and apply adult education skills to training
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The role of tobacco dependence treatment within a comprehensive tobacco control strategy
Learning Objectives
At the end of the presentation the participants will be able to:
Recognize treatment of tobacco dependence as a key component of any comprehensive tobacco control initiative.
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Quitting has the potential to save lives in the short & medium-term
If adult consumption were to decrease by 50% by the year 2020, approximately 180 million tobacco-related deaths could be avoided.
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Treatment of tobacco dependence as part of Assessment and management of cardiovascular risk (PHC-level)
WHO/ISH Pocket guidelines for predicting 10-year risk of a fatal or non-fatal major heart attack and stroke risk based on: Age Sex Blood pressure Smoking status Blood cholesterol Presence or absence of diabetes Recommendations: Smoking cessation Dietary changes Physical activity Weight control Alcohol intake reduction Antihypertensive drugs Lipid-lowering drugs Antiplatelet drugs
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Story 2-What happened after the US raised tobacco tax in spring 2009?
The US raised federal tax in 2009. The impact of the tax increase on calls to US quitlines.
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Question what do these two stories imply about treatment of tobacco dependence? Implementing population level tobacco control policies can motivate people to stop smoking and increase their demand for tobacco dependence treatment.
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Question what does this story imply about treatment of tobacco dependence?
It is important to provide tobacco users effective support as much as possible to assist in their behaviour change. Or else, they will use whatever they can find.
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Summary
Treatment of tobacco dependence is a key component of any comprehensive tobacco control strategy. Providing support for tobacco users to quit can also help reduce smoker's resistance to the implementation of population-level tobacco control policies Health Professionals have a prominent role to play All health professionals in the everyday health-care setting need to address tobacco dependence as part of their standard of care practice!
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Learning objectives
At the end of the presentation the participants will be able to:
Describe health, social and economic impact of tobacco use on tobacco users and others
Clarify common misconceptions held by tobacco users Explain the benefits of quitting tobacco use
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Brainstorming
What is the impact of tobacco use on tobacco users and others?
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Health impact
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Tobacco use and second-hand smoke damage every part of the body
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A risk factor for six of eight leading causes of death in the world
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Cancer of the head and neck, esophagus and pancreas, as well as oral diseases Heart disease Low-birthweight babies
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Light, "ultra-light". "low tar" or "mild" cigarettes are less harmful? Are 'rollies' safe to smoke? Will cutting down the number of cigarettes I smoke reduce my health risks? Only old people get ill from smoking don't they? Does everyone who quits smoking put on weight?
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China 5.00 billion Egypt 1.25 billion *:Direct health care costs plus indirect costs, including productivity losses,
absenteeism and other socioeconomic costs.
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Tobacco use is costly with 5-15% of tobacco user's disposable income is spent on tobacco
Source: WHO The tobacco atlas, first version
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Brainstorming
What are the benefits of quitting tobacco use?
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Health benefits
Time since quitting Within 20 minutes 12 hours 2-12 weeks 1-9 months 1 year 5 years Beneficial health changes that take place Your heart rate and blood pressure drop. The carbon monoxide level in your blood drops to normal. Your circulation improves and your lung function increases. Coughing and shortness of breath decrease. Your added risk of coronary heart disease is about half that of a smoker's. Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting. Your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases.
10 years
15 years
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Learning objectives
At the end of the presentation the participants will be able to:
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Brainstorming
Why do people smoke?
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Chemical addiction
A major factor that maintains a smoking habit over time is addiction to nicotine Nicotine has been shown to have effects on brain dopamine systems similar to those of drugs such as heroin and cocaine.
- It gradually increase the number of nicotinic receptors in the brain
- Smokers need greater amounts of tobacco to achieve the same levels of satisfaction.
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Chemical addiction
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Nicotine Withdrawal
Nicotine increases the number of nicotinic receptors in the brain When receptors are empty, they make you feel uncomfortable and increase your urge to smoke
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Nicotine Withdrawal
Common withdrawal symptoms : Headaches Coughing Cravings Increased appetite or weight gain Mood changes (sadness, irritability, frustration, or anger) Restlessness Decreased heart rate Difficulty concentrating Flu-like symptoms Insomnia
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Nicotine Withdrawal
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Emotional/psychological connection
Smokers link feelings with cigarettes via the process of withdrawal and operant conditioning
Some of the emotional connections that may be associated with smoking:
Stressed Happy Sad Angry craving craving craving craving cigarette cigarette cigarette cigarette
Your cognitions (i.e. thoughts and beliefs) have effect on smoking too.
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All three types of factors influencing smoking need to be explored and referred to in stop smoking support programmes.
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Group discussion
Participants to discuss with the person sitting next to them:
Two ways in which you should use the knowledge of tobacco addiction when delivering brief interventions
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Learning objectives
At the end of the presentation the participants will be able to:
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Preparation
Ask group for their experiences of talking to patients about smoking
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Definition: Advice to stop using tobacco, usually taking only a few minutes, given to all tobacco users, usually during the course of a routine consultation or interaction. Used interchangeably with brief advice. Purpose: The primary purpose is to help the patient: understand risk of tobacco use and the benefits of quitting motivate them to make a quit attempt
Can also be used to encourage those heavy tobacco users to seek or accept a referral to more intensive treatments within their community
Source: WHO FCTC Article 14 Guidelines
Brief intervention
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Brief tobacco interventions even small effect sizes can have significant population impact if they are delivered routinely and widely across a healthcare system:
Reach: In the developed world, 85% of the population visit a primary health care clinician at least once per year Effectiveness: 40% of case will make a quit attempt; quit rate of 2% Cost: very low (a few minutes opportunistic intervention as part of PHC providers' routine practice).
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Ask
We need to be asking ALL of our patients if they smokemaking it part of our routine. Only then do we start to make a real difference to the smoking rates around us. Smoking should be asked about in a friendly way its not an accusation!
Advise
Assess Assist Arrange
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Ask
Advise Assess
Assist Arrange
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Ask
After giving advice we need to assess the patients readiness to quit. This will be determined whether they want to be a non-smoker, and by if they think they have any chance of quitting successfully. More on the assess stage later!
Advise Assess
Assist Arrange
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Ask
If the patient is ready to quit then theyll need some help from us. We need to assist tobacco users in developing a quit plan or to tell them about the specialist support if that is available. The support needs to be described positively but realistically. More on this later.
Advise Assess
Assist Arrange
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If the patient is willing to make a quit attempt we should arrange follow-up around 1 week after the quit attempt, or arrange referrals to the specialist support.
Arrange
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Ask Advise
Assess
Assist Arrange
Five Rs
Not Ready to Quit
Ready to Quit
End positively
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Ask
2.AAR
Advise
Advise Brief advise
Ask
3.ABC
Refer
Ask
Cessation
Make referral to the Quit line or cessation services Provide cessation support and medication Arrange follow-up within a week 70
Train-the-Trainer: Ghana
Summary
The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that a PHC provider can do to help a tobacco user within 3 to 5 minutes in PHC settings You can start and stop at any step as indicated in the diagram
Ask
Arrange
Advise Assess
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Assist
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Summary
Brief interventions may be delivered anywhere in the hospital setting, in the out-patient clinic or in the community. Brief interventions take a few minutes but if done routinely they can significantly increase the numbers of people quitting and save lives!
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COFFEE BREAK
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Asking, Advising
-The Five As
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Learning objectives
At the end of the presentation the participants will be able to:
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Preparation
Ask group for their thoughts on advice giving. How does giving advice on clinical issues differ from giving advice on behaviour change
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Ask
Ask about tobacco use at EVERY encounter. Keep it simple:
Do you use tobacco? Does anyone else in your home use tobacco?
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Advise to Quit
Advise to quit in clear, strong and personalised manner!
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Evidence shows that providing tailored information on smoking is more effective than providing standardised information.
Source: Lancaster & Stead , 2005
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Tailoring Advice
In a brief intervention: There are a number of factors that a practitioner may think about when give personalized advice It would be impossible to tell patients about every possible effect of tobacco use because the effects of tobacco use are very wide ranging, including a variety of health effects When how to tailor advice for a particular patient is not obvious, a useful strategy may be to ask the patient: What do you not like about being a smoker? The patients answer to this question can be built upon by the practitioner with more detailed information on the issue raised
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Tailoring Advice
Example: Doctor: What do you not like about being a smoker? Patient: I suppose I dont like the way it makes me cough Doctor: Yes. Smoking does effect lung function, and it will get worse over time if you continue to smoke. Example: Doctor: What do you not like about being a smoker? Patient: Well, I dont like how much I spend on tobacco. Doctor: Yes, it does build up. Lets work out how much you spend each month. Then we can think about what you could buy instead!
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Role Plays
One trainee will volunteer to play the role of the practitioner. He or she will:
A) Ask about the patients smoking B) Give some tailored advice.
The facilitator will play the role of the three fictional smokers: Jack, Rhea and Thomas The facilitator will invite comments from the group
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-The Five As
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Learning objectives
At the end of the presentation the participants will be able to:
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readiness to quit
self-efficacy
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In relation to the first question someone needs to be quite sure that they want to be a non-tobacco user. Only a Yes will do! In relation to the second question there is room for some doubt. It is OK to be unsure but a definite No indicates a problem.
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Yes
Unsure
No
Yes
Unsure
No
If the answer is "No" indciates that the tobacco user is NOT ready to quit and we should deliver the 5R's intervention.
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Evaluation of Day 1
Provide a brief review of what has been learned and a preview of what is to come in the second day. Allow 5 minutes so that trainees may ask questions at the end.
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