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TABLE OF CONTENTS
PAGES TOPIC

1 Topic 1 Tobacco Burden in Malaysia

7 Topic 2 Tobacco Addiction Smoking Related Diseases and Its Impact

17 Topic 3 Smoking Cessation Services at Primary Care Level

23 Topic 4 Enhancing Motivation to Quit Smoking Programme

51 Topic 5 Brief Clinical Interventation: 3As, 5As and 5Rs

61 Topic 6 Management of Quit Smoking Services at Health Clinic

71 Topic 7 Promotion and counselling: Quit Smoking programme in Health

Clinic Tanglin

83 Topic 8 Pharmacological Interventation in Smoking Cessation

99 Appendix 1
Pilot Project by WHO Regarding Brief Intervention of Quit Smoking Programme
in Health Clinics

1. Health Clinic Batu Pahat, Johor

2. Health Clinic Jasin, Melaka

3. Health Clinic Seberang Jaya, Pulau Pinang

4. Health Clinic Kuala Berang, Terengganu

135 Appendix 2
Table of contents

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CONTRIBUTORS
Dr Ho Bee Kiau
Family Medicine Specialist
Health Clinic Botanic Klang, Selangor.

Dr Nor Azlin binti Amat

Family Medicine Specialist
Health Clinic Kuala Berang,
Hulu Terengganu, Terengganu.

Dr Eva Wong Yi Wah

Medical Officer
Health Clinic Jasin, Melaka

Dr Zarihah binti Mohd Zain

Public Health Physician
Control Disease Division
Ministry of Health Malaysia

Dr Rasimah binti Ismail

Head Sector of Family Development
Petaling District Office Selangor

Dr Salmah Nordin
Family Medicine Specialist
Health Clinic Rawang Selangor

Dr Yunus bin Shariff

Family Medicine Specialist
Health Clinic Batu Pahat, Johor.

Dr Nazma binti Salleh

Public Health Physcian
Primary Medical Care Unit
Ministry of Health Malaysia
Contributors

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CONTRIBUTORS
Dr Sallehudin bin AbuBakar
Senior Consultant
Public Health Physcian
Hulu Langat District, Selangor

Dr Naimah binti Abdul Majid

Medical Officer
Health Clinic Seberang Jaya, Pulau Pinang

Dr Fatanah binti Ismail

Public Health Physcian
Primary Medical Care Unit
Ministry of Health Malaysia

Swinderjit Jag Singh

Staff Nurse
Health Clinic Tanglin

Dr MohamadHaniki bin Nik Mohamed

Associated Professor
Chief Coordinator of Certified Smoking
Cessation Service Provider CSCSP Programme
& Deputy Dean (Academic)
Kulliyah of Pharmacy
International Islamic University Malaysia (IIUM)
Contributors

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EDITORS
. Dr Fatanah binti Ismail
Public Health Physician
Family Health Development Division
Ministry of Health Malaysia

Dr Nazma binti Salleh

Public Health Physician
Family Health Development Division
Ministry of Health Malaysia

Dr Natasya Nur binti Mohd Nasir

Assistant Director
Primary Medical Care Unit
Family Health Development Division
Ministry of Health Malaysia

EDITORS

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INTRODUCTION
Health hazards of cigarette smoking are well documented in a great number of research papers
from many countries and there are strong associations between smoking with morbidity and
mortality. Smoking is a nicotine addiction and classified as “Substance Use Disorder” under
International Classification of Disease (ICD -10) and “Nicotine Dependence” or “Nicotine
Withdrawal” under Diagnostic and Statistical Manual of Mental Disorder (DSM IV).

In Malaysia, the number of smokers is increasing. Data from the Malaysia Global Adult
Tobacco Survey 2011 (GATS 2011) revealed that 23.1% or 4.7 million population aged 15 years
above smoked. The prevalence of tobacco users among men and women were 43.9% and 1%
respectively. Data also showed that only 9.5 % have quit smoking in 2011. The GATS findings
also documented 4 in 10 adults who worked outdoors (2.3 million) were exposed to tobacco
smoke at the workplace, 4 in 10 adults (7.6 million) were exposed to tobacco smoke at home and
7 in 10 adult (8.6 million) who visited restaurants were exposed to tobacco smoke.

Intervention programs need to be strengthened in line with WHO Global target to decrease
smoking prevalence by 30 % in all countries by 2015. Smoking cessation services had been
established at government facilities as early as in the year 2000 when the Family Health and
Development Division provided these services in 729 primary health care clinics. Smoking
cessation services are run by the primary health care team which consists of doctors, pharmacists
and paramedics.

In the earlier years, health education and counseling was the mainstay of treatment. Later
on clients at health clinics were treated with non -pharmacotherapy and pharmacotherapy
options. Since 2010, nicotine based and non-nicotine based treatment had been used in the
health clinics. At present nicotine replacement therapy (NRT) and varenicline are made available
for smoking cessation at health clinics. However, the mode of treatment would be determined
by the attending doctor, after assessment and discussion with the client. Average quit rate for
2013 was 17.2%.

Compilation of knowledge, materials and experiences gathered from the national level smoking
cessation course in 2012 resulted in the development of this module. Family Medicine Specialists,
Public Health Specialists and academics from the Islamic International Universities contributed
to the contents of this module. Good practices and innovation in implementation of smoking
cessation approaches are shared in this module.

Technical staffs needed training in order to be competent in delivering smoking cessation

services. Hence, regular in service courses involving Family Medicine Specialists, Pharmacist,
Assistant Medical Officers and nurses should be conducted. The training module will be main
reference material for the continuous training needed, thus contributing to an effective system
to serve more clients and provide quality interventions especially techniques of motivational
counselling besides pharmacotherapy to helps smokers to quit.
Introduction

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 TOPIC 1

Tobacco Burden
in Malaysia

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LEARNING OBJECTIVE
This topic provides the background imformation about the tobacco burden in Malaysia

• Statistic for the Malaysia population who are smoked.

• Data regarding contribution of tobacco to the leading causes of deaths in the world.
• Financial costs of tobacco in Malaysia.
• Lifetime benefits of smoking cessation based on the Guide in quiting Smoking from the
American Cancer Society.

SLIDE
Effects of Tobacco
1
• Health effect to active smokers
• Health effects to passive smokers
• Financial effects
• Social effect
• Environmental effects

SLIDE
Tobacco use is a risk factor for six of eight leading causes of death in the
2
world
Tobacco Burden In Malaysia

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Global Adult Tobacco Survey 2011 SLIDE

3
Adult Current Tobacco Current Cigarette Tobacco
Smokers Smokers Ex-Smokers

Occasional

Occasional

Smokers
Overall

Overall

Overall
Daily

Daily

Daily
Overall 23.1 20.9 2.3 22.9 20.6 2.2 2.3 9.5
Male 43.9 39.9 4.1 43.6 39.4 4.0 4.4 9.4
Female 1.0 0.7 0.4 1.0 0.7 0.3 0.1 10

Tobacco Use – Prevalence adolescents SLIDE

4
Prevalence GYTS 2003 GYTS 2009

Overall Boys Girls Overall Boys Girls

Ever smoked cigarettes 33.1 % 54.6 % 11.5 % 30.0 % 46.7 % 12.4 %

Ever smokers, 1st 16.4 % 14.1 % 28.8 % 22.8 % 19.3 % 35.9 %

smoked cigarettes
before age 10
Currently smoking 20.2 % 36.3% 4.2% 18.2 % 30.9 % 5.3 %
cigarettes
Currently using other 8.1% 8.8% 7.5% 9.5 % 13.0 % 5.7 %
tobacco products

Never smoke likely to 15.5 % 21.4 % 12.4 % 10.7 % 15.7 % 7.7 %

initiate smoking in the
next year

Tobacco Use – Prevalence (3rd National Health & Morbidity Survey SLIDE
2013 - NHMS 3) 5
Tobacco Burden In Malaysia

Adult Ever Smoker Current Smoker Ex-Smoker

Overall 27.0% 21.5% (2.73 M) 5.4%

Male 57.6% 46.4% (2.61 M) 11.0%

Female 2.5% 1.6% (0.12 M) 0.9%

Urban 24.1% 18.9% (1.56 M) 5.0%

Rural 32.3% 26.2% (1.17 M) 6.0%

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SLIDE
Smoking is a disease
6 • Tobacco smoking is classified as a Mental & Behavioral Disorder under
WHO International Classification of Diseases (ICD-10) coded as F17.2
• Other ICD 10 codings are Z50.8, Z71.6, Z72.0, Z58.7, Z81.2 & Z86.4
respectively for contacts with health services, passive smoking &
hazards related to family history
• Tobacco users are nicotine addicts

Financial Burden of Tobacco in Malaysia

SLIDE
Annual cost for IHD, Lung Cancer and Chronic Obstructive Pulmonary
7 Disease
Mean Min Max

Patient (mil RM) 949.8 682.3 1730.6

Provider (mil RM) 1975.0 925.0 3257.7

Total (mil RM) 2924.8 1607.3 4988.3

% of GDP 0.74 0.41 1.27

% of NHE 16.49 9.06 28.12

% MOH budget 26.14 12.24 43.11

SLIDE Social Costs Enviroment Costs

8
• Widows • Deforestation
• Orphans • Litter
• Family unrest • Fires
• Problems of youths • Pollution : Air & Water
• Juvenile delinquency
• Drug addiction
Tobacco Burden In Malaysia

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Potential Lifetime Health Benefits of Quitting SLIDE

1. CDC. Surgeon General Report 2004: http://www.cdc.gov/tobacco/ 9
sgr/sgr_2004/sgranimation/flash/index.html. American Cancer
Society. Guide to Quitting Smoking. Available at: http://www.cancer.
org. Accessed June 2006. 2. American Cancer Society. Guide to Quitting
Smoking. Available at: http://www.cancer.org. Accessed June 2006. 3.US
Department of Health & Human Services. The Health Benefits of Smoking
Cessation: A Report of the Surgeon General. Centers for Disease Control
and Prevention (CDC), Office on Smoking and Health. 1990. Available at:
http://profiles.nlm.nih.gov/NN/B/B/C/T/. Accessed July 2006.

Tobacco Burden In Malaysia

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 TOPIC 2

Tobacco Addiction
Smoking Related
Diseases and Its Impact

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LEARNING OBJECTIVE
• Emphasize on chemical substance in the cigarette content and each of the
chemical side effects.
• Learn the human pathophysiology of nicotine addiction with withdrawal syndrome,
nicotine cycle and the rewarding pathway with the timeline process of quit smoking benefit.

SLIDE
Why do people start smoking?
1
• Peer pressure
• To feel good
• To be differrent
• Curiosity
• For fun

SLIDE
Why do people continue smoking?
2
Host: Addiction, genetic, family, and
mental illness
Agent: Easily available HOST
Environment: Occupation, Peer,
Tobacco Addiction Smoking Related Diseases and Its Impact

Culture

Environment Agent
This explains the multiple discipline
approach in quit smoking activity

SLIDE
Do you get addicted to tobacco?
3
• Cigarettes and other forms of tobacco are addicting.
• Nicotine is the drug in tobacco that causes addiction.
• The pharmacologic and behavioral processes that determine tobacco
addiction are similar to those that determine addiction to drugs such as
heroin and cocaine.

U.S. Department of Health and Human Services. (1988). The Health

Consequences of Smoking: Nicotine Addiction. A Report of the Surgeon
General.

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SLIDE
Understanding nicotine function • Nicotine is readily absorbed :
1. Through intact skin.
4
Absorption is pH dependent
2. In the small intestine but has
• In acidic media
low bioavailability (30%) due to
- Ionized ==> poorly absorbed
first-pass hepatic metabolism.
across membranes
3. Across respiratory epithelium.
• In alkaline media
4. Lung pH = 7.4
- Not ionized ==> well absorbed
5. Large alveolar surface area
across membranes
6. Extensive capillary system in lung
- At physiologic pH (7.3–7.5),
• Nicotine half life 2 hours
~31% of nicotine is unionized
• Nicotine is excreted via kidneys (pH
• The pH inside the oral cavity is 7.0.
dependent; with acidic pH)
Beverage can alter pH and affect
• Nicotine is excreted through breast
absorption.
milk

SLIDE
Nicotine Distribution
5
Nicotine reaches the brain within 11 seconds.

Arterial
Venous

Tobacco Addiction Smoking Related Diseases and Its Impact

Henningfield et al. (1993). Drug Alcohol Depend 33:23–29.

Central nervous system SLIDE

Nicotine Pharmacodynamics Cardiovascular system Exocrine Glands 6
Nicotine binds to receptors
Gastrointestinal
in the brain and other sites system
in the body. Adrenal medulla

Other:
Neuromuscular Peripheral nervous system
junction
Sensory receptors
Other organ

Nicotine has predominantly stimulant effects.

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SLIDE
How does nicotine act on receptors?
7
• Nicotinic acetylcholine receptors present in the brain at the reward pathway
and other part of body
• Mimics naturally occurring chemical messenger - acetylcholine
• Attaches to nicotinic - acetylcholine receptors and triggers release of
dopamine
• Dopamine is the primary neurotransmitter of the reward pathway
• All drugs of abuse increase dopamine levels in the brain reward pathway
although they often act through separate mechanisms

SLIDE
The Reward Pathway
8
Tobacco Addiction Smoking Related Diseases and Its Impact

• Located in the limbic system – functions to monitor internal homeostasis,

mediate memory, mediate learning and experience emotion
• Includes the hypothalamus, amygdala, hippocampus, nucleus accumbens
(NA), the ventral tegmental area (VTA), locus ceruleus and the prefrontal
cortex

SLIDE NEUROCHEMICAL and RELATED EFFECTS of NICOTINE

9
DOPAMINE Pleasure, reward

NOREPINEPHRNE Arousal, appetite suppression

N
I ACETYLCHOLINE Arousal, cognitive enhancement
C
O GLUTAMATE Learning, memory enhancement
T
I Mood modulation, appetite
SEROTONIN
N suppression
E
B- ENDORPHIN Reduction of anxiety and tension

GABA Reduction of anxiety and tension

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SLIDE
Nicotine addiction
10
• Cigarettes deliver rapid doses of nicotine- ‘bolus’
• Reinforcing through reward and withdrawal
• Animal and human studies provide strong and consistent evidence that
nicotine is highly addictive

SLIDE
Nicotine addiction cycle
11
Nicotine use for pleasure, enhance performance, mood regulation

Nicotine use to Tolerance and physical

Self-medicate withdrawal dependence
symptoms

Tobacco Addiction Smoking Related Diseases and Its Impact

Nicotine abstinence produces
withdrawals symptoms

SLIDE
Nicotine Addiction Cycle
12

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SLIDE Nicotine Addiction

13
1. Tobacco users maintain a minimum serum nicotine concentration in order to
– Prevent withdrawal symptoms
– Maintain pleasure/arousal
– Modulate mood

2. Users self-titrate nicotine intake by

– Smoking/dipping more frequently
– Smoking more intensely
– Obstructing vents on low-nicotine brand cigarettes

SLIDE
Percentage of those ever using a drug who become addicted
14
31.9

23.1

15.4 16.7
Tobacco Addiction Smoking Related Diseases and Its Impact

Alcohol Cocaine Heroin Tobacco

SLIDE
Learning Processes Underlying Drug Addiction (N. White, 1996)
15
1. Amygdala-NAc (Incentive) – promotes approach to and interaction with
drug related cues (produces behavior unconsciously)
2. Caudate-Putamen (Habit) – promotes repetition of behaviors
performed in the presence of drug-related stimuli (produces behavior
unconsciously)
3. Hippocampus (Declarative) – promotes focusing of cognitive processes
on drug related situations (conscious)

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SLIDE
Brain Development
16
1. Human brains continue to develop after birth and are not fully developed
until late adolescence/early adulthood
2. Amygdala is on-line at birth
3. Hippocampus is on-line about 18 months of age
4. Prefrontal cortex (judgment) not fully developed until late adolescence/
early adulthood
5. Use of drugs/alcohol can impede development

SLIDE
Tobacco dependence is:
17
• ‘chronic relapsing disorder’
• “nicotine addiction deserves medical treatment like any drugs dependence
and chronic disease”

Tobacco Addiction Smoking Related Diseases and Its Impact

Fiore et al, US Department of Health and Human Services, June 2000
WHO 2003

SLIDE
Nicotine
18
Nicotine is a psychoactive drug affecting mood and performance and is the
cause of addiction to tobacco

Repeated exposure to …produces adaptation …resulting in nicotine

nicotine… of the neural receptors… dependence

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SLIDE Aspects of addiction

19
1. Tolerance
– Increasing doses of drug needed to obtain the same effect.

2. Dependence
– characterized by a withdrawal syndrome that accompanies abstinence
or reduction

3. Withdrawal syndrome
– Symptoms after abrupt cessation of, or reduction in, Often results in
physical and mental discomfort

SLIDE
Addiction / dependence
20
Key issues
• Use of the drug (nicotine) to maintain a blood (brain) level
(pseudo-primary behavior: loss of autonomy
• Withdrawals → relapse
• Use in the face of medical and social detriment
Tobacco Addiction Smoking Related Diseases and Its Impact

SLIDE Nicotine withdrawal

21
1. Withdrawal symptoms are common to most regular smokers
2. Common barriers to smoking cessation:
- Stress
- Fear of failure
- Peer and social pressure
- Weight gain

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Acute withdrawal symptoms SLIDE

22
• Cravings [urges to smoke]
• Anxiety
• Irritability
• Mood changes [aggression]
• Reduced concentration

Chronic withdrawal symptoms SLIDE

23
1. Insomnia
2. Cough
3. Bowel changes
4. Appetite changes (increase)
5. Tingling and dizziness
6. Mood changes (depression)
7. Aphthous stomatitis

Tobacco Addiction Smoking Related Diseases and Its Impact

SLIDE
Lapse and relapse 24

Lapse: important to prevent bolus of nicotine as it is irresistibly rewarding

-95% of lapses are relapses
-85% of lapses are just one puff (within 1-4 days of a quit attempt

Relapse; in general community population for those who spontaneously quit

smoking are untreated
- Half resume smoking in the 7 days
- at 2 weeks 40% of population continue to abstain
- at 1 month 2% continue to abstain

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SLIDE Summary
25
1. Nicotine is produce in bolus during smoking
2. Ach receptor stimulation causes Dopamine release
3. Reward and withdrawal
4. Addiction is a chronic relapsing mental illness
5. Nicotine addiction is ‘legal’
6. Should treat nicotine addiction
Tobacco Addiction Smoking Related Diseases and Its Impact

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 TOPIC 3

Smoking Cessation
Services at Primary
Care Level

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LEARNING OBJECTIVE
• Overview on policy, scope of services at different type of health clinic and implementation Quit
Smoking Services in primary health care.
• Management process including setting equipment, man power and monitoring.
• Drugs formulary which are available in health clinic.
• Challenges in implementation in primary health care.

SLIDE
1 Quit Services

• Quit Smoking Clinics/Services

• Implemented To Health Clinics and Hospitals since year 2000
• Screening, Counseling and Pharmacotherapy

SLIDE
2 National Smoking Cessation Programme

General Objectives
Provide comprehensive support and assistance to help smokers quit
smoking

Specific Objectives
Smoking Cessation Services at Primary Care Level

1. Develop skills of assisting smokers to quit among all health

professionals
2. Make quit smoking services widely available and accessible at all levels
of health care
3. Encourage and motivate smokers utilize the services provided.
4. Involve all stakeholders in partnership to help smokers quit

Strategies
1. Improve capacity building in area of expertise and infrastructure that will
facilitate the establishment of comprehensive and effective quit smoking
programme
2. Promote and advertise the availability of quit smoking services to the
public and specific groups
3. Make all available all evidence-based treatment modalities
4. Inform and educate smokers about the benefits of quitting smoking

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Recommendations SLIDE
3
Three types of treatment should be included in any tobacco prevention
effort
1. Tobacco cessation advice incorporated into primary healthcare services
(feasible, effective and efficient)
2. Easily accessible and free quit lines
3. Access to free or low cost cessation medicines.

SLIDE
Quit Services in Primary Health Care – The Concept
4
Terminology
Quit Smoking Clinic / Khidmat Berhenti Merokok (KBM)
Services
1. Health Promotion
2. Screening
3. Counseling
4. Pharmacotherapy

Smoking Cessation Services at Primary Care Level

SLIDE
Scope of Services by Clinic Level
5
Universal Intermediate Advanced

Health education 3 3 3

Screening (3As, 5As) 3 3 3

Counseling 3 3 3

Pharmacological Refer +/- (FMS) Yes (A/KK)

Follow-up Non Yes Yes

Pharmacological

Tools Peak Flow Peak Flow Peak Flow

CO Analyzer CO Analyzer
+/-Drugs Drugs

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SLIDE Building a Cessation System

6
MEDICAL
TREATMENT

INTENSIVE
COUNSELLING

BRIEF
ADVICE

SLIDE Definition of Terms

7
1. Tobacco/Smoking Cessation
Process of stopping the use of any tobacco product, with or without
assistance
2. Brief Advice
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.
3. Treatment Of Tobacco Dependence
Provision of behavioural support or medications or both to tobacco users,
Smoking Cessation Services at Primary Care Level

to help them stop their tobacco use

SLIDE
8 Giving Brief Advice – Increases quit rate by 1-3% in the long term

1. Advice on the risk of smoking to health

2. Use different messages for different people
3. State that you understand that quitting can be hard, but the more you try
to quit, the higher the chance that you will succeed
4. Know that there are treatments that will increase success to up to 300%
5. Offer /refer for treatment

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Quit Smoking Services SLIDE

9
1. Services should be activated
2. Quit Smoking Services Course
• Attachment at successful Health Clinic (eg: JKWPKL)
3. Monitoring
• Stregthen the data management and collection
• Family Health Development Division (FHDD) will monitor the Quit
Smoking data or reten

New format for the Quit Smoking Services clinic has been distributed since
last February (BPKK/KBM 1/2012 - BPKK/KBM 5/2012)

1. Allocation
• Use the current Operational Budget
• Family Health Development Division (FHDD) will ask for Dasar Baru 2013
2. Edition 2012
• Quit Smoking Guideline will be distribute to states.
• Each patient who is undergoing the treatment will have their own folder.
• Flip Chart

Smoking Cessation Services at Primary Care Level

SLIDE
Drugs Formulary: Health Clinics
10
Nicotine Patch
a. Nicotine patch 7 mg
b. Nicotine patch 14 mg
c. Nicotine patch 21 mg
Nicotine Gum
a. Nicotine gum 2 mg
b. Nicotine gum 4 mg

Varenicline (Champix)
a. Varenicline 0.5 mg / tablet
b. Varenicline 1 mg / tablet
Lozenges
a. Lozenges 2 mg
b. Lozenges 4 mg

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SLIDE
11 Challenges in Implementation at Primary Health Care

1. Turn Over Staff

2. Allocation for Medication
3. High Defaulter Rate

SLIDE
12 Conclusion

1. Every clinic must have KBM

2. Brief Intervention (3As and 5As at each entry point)
3. Quit Smoking Training should be conduct continuously
4. Record and monitoring
Smoking Cessation Services at Primary Care Level

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 TOPIC 4

Enhancing
Tobacco
Motivation
Burden
to
Quit
in Smoking
Malaysia
Model and Process of
Behaviour Change

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LEARNING OBJECTIVE
• Concept of motivation
• The main principles of technique for motivational interventional skill and interviewing.
• Application of 5Rs strategies for tobacco interventions at primary care level in handling a situation
among the reluctant smoker who attended our clinic daily.

A. Enhancing Motivation To Quit Smoking

SLIDE
1 Motivational Intervention

1. For patients not ready to make a quit attempt at this time health care
provider should use motivational intervention to increase patients’
motivation to quit smoking
2. Patients unwilling to make a quit attempt may lack information about
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

the harmful effects of tobacco, financial resources, may have fears or

concerns about quitting, or may be demoralized because of previous
relapse.
3. Such patients may respond to a motivational intervention to educate,
reassure and motivate

SLIDE
2 The concept of motivation

1. Motivation can be defined as the probability that a person will enter into,
continue, and adhere to a specific change strategy
2. Motivation is a key to change
3. Motivation is multidimensional
4. Motivation is dynamic
5. Motivation is fluctuating

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SLIDE
5Rs Strategy 3

1. The 5Rs strategies are: RELEVANCE, RISKS, REWARDS, ROADBLOCKS AND

REPETITION
2. Motivational intervention are most likely to be successful when the HCPs
apply all the key principles and strategies of motivational interviewing

RELEVANCE
• Encourage the patients to discuss why quitting is personally relevant,
being as specific as possible
• Motivational information has the greatest impact if it is relevant to a
patient’s disease status, risk, family or social situation (example having
children at home, health concerns, age, gender, and other important

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

patient’s characteristics such as prior quitting experience and personal
barriers to quitting)

RISKS
• The health care provider should ask the patient to identify potential
negative consequences of smoking
• The health care provider may suggest and highlight those that seem
most relevant to the patient
• Emphasize that smoking low tar/nicotine or use of other form of
tobacco
will not eliminate these risks
• Examples of risks:
- Acute risks
a. Shortness of breath, reduced stamina
b. Exacerbation of asthma
c. Impotence , infertility
- Long term risks
a. Heart attack and strokes
b. Lung and other cancers
c. COPD and other long term disability
- Environmental risks
a. Increased risk of lung cancer and heart attack in spouse
b. Increased risk of respiratory infection and otitis media in children

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REWARDS
1. The HCP should ask the patient to identify potential benefits of smoking
cessation
2. The HCP may suggest and highlight those that seem most relevant to the
patient
3. Examples of rewards:
a. Improved health
b. Improved sense of smell
c. Food will taste better
d. Save money
e. Feel better physically
f. Not worry about exposing others to smoke
g. Set good example for children
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

ROADBLOCKS
1. The HCP should ask the patient to identify barriers or impediments to
quitting
2. Note elements of treatment (CBT , problem solving, pharmacotherapy)
that cold address the barriers
3. Typical barriers might include:
a. Withdrawal symptoms
b. Weight gain
c. Lack of support
d. Depression
e. Enjoyment of tobacco

REPETITION
1. The motivational intervention should be repeated every time an
unmotivated patient visits the clinic setting
2. Smokers who have failed in previous quit attempts should be told that
most people make repeated quit attempts before they are successful

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What is Motivational Interviewing? SLIDE

4
• Client-centered, directive method for enhancing intrinsic motivation to
change by exploring and resolving ambivalence (Miller & Rollnick, 2002)
• A collaborative, person-centered form of guiding to elicit and strengthen
motivation for change (Miller & Rollnick, 2009)

The spirit of motivational interviewing SLIDE

5
• Motivation to change is elicited from the client, and not imposed from
without
• It is the client’s task, not the counsellors to articulate and resolve his/

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

her ambivalence
• Direct persuasion is not an effective method for resolving ambivalence
• The counselling style is generally a quiet and eliciting one
• The counsellor is directive in helping the client to examine and resolve
ambivalence
• Readiness to change is not a patient trait, but a fluctuating product of
interpersonal interaction
• The therapeutic relationship is more like a partnership or companionship
than expert/recipient roles

Principles of Motivational Interviewing (MI) SLIDE

6
1. MI is founded on 5 key principles “READS”
a. Roll with resistance
b. Express empathy
c. Avoid argumentation
d. Develop discrepancy
e. Support self-efficacy

2. The principles are not necessarily applied in this particular order, and all
these techniques should be used through out the interaction

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SLIDE
7 Roll with resistance

1. Resistance can take several forms such as

a. Negating
b. blaming
c. excusing
d. minimizing
e. arguing
f. challenging
g. interrupting
h. i gnoring
2. In MI one does not directly oppose resistance but rather rolls or flows with
it.
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

3. Direct confrontation will create additional barriers that will make change
more difficult
4. A person’s resistance is expected and should not be viewed as a negative
outcome
5. Exploring the reasons behind the resistance behaviour can lead the person
to seriously consider possibilities of change

Rolling with resistance

1. Avoid a direct head-on argument with the person whose behaviour you
would like to see change
2. Show that you heard what the person has said using (reflective listening
skill – is a way of getting alongside the person even if you don’t agree and
may help to diffuse or prevent some of his instinctive defensiveness)
3. Encourage the person to come up with possible solution or alternative
behavior of himself - rather than forcing suggestion on the person. This
can help him feel empowered rather than attacked

Reflective listening

1. Reflective listening involves listening carefully to clients and then making

reasonable guess about what they are saying
2. The HCP then responds by paraphrasing, summarizing or reflecting it back
to him in a way which shows that you have heard what he is saying even if
you don’t agree with it
3. Example of reflective listening (specific)
“It sounds like you don’t want to quit smoking at this time”

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Examples of reflective listening (generic):

1. “It sounds like ……..”
2. “What I hear you saying…….”
3. “So on the one hand it sounds like….and, yet on the other hand…”
4. “It seems as if…”
5. “I get the sense that…”
6. “It feels as though……”

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SLIDE
8 Expressing empathy

• Because motivational intervention relies to a great extent on establishing

and maintaining rapport with the patient, the ability to express empathy
is important
• Requires skillful reflective listening to understand patient’s feeling and
perspective without judging, criticizing or blaming
• An attitude of acceptance and respect contributes to the development of
an effective helping relationship and enhances the patient’s self esteem
• Empathic response demonstrate that the HCP understand the person’s
point of view and provide an important basis for engaging the person in a
process of change
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
9 Avoid argumentation

• Resistance to change is strongly affected by the HCP’s response;

therefore arguments should be avoided
• Direct confrontation usually result in defensive reactions and increased
resistance to change
• Resistance is an indication that the HCP should change strategy rather
than argue.

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SLIDE
Develop discrepancy 10

• The principle of developing discrepancy is based on the understanding that

motivation for change is created when the person perceives a discrepancy
between their behaviour and personal goals.
• This often involves identifying and clarifying the person’s own goals
• The goals need to be those of the person and not the HCP, otherwise the
person will feel as though they are being coerced and may become more
resistance to change
• Use decisional balance strategy to develop discrepancy
• Reflecting back and examining the pros and cons will help discrepancy
emerge
• Discrepancy may be triggered by an awareness of a discontent with the
costs of one’s present course of behaviour- when behaviour is seen as

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

conflicting with one’s health, success or family happiness, change is more
likely to occur
• To develop discrepancy the counsellor ought to
• Clarify important goals for the patient
• Explore the consequences or potential consequences of the patient’s
current behaviours
• Create and amplify in the patient’s mind a discrepancy between their
current behaviour and their goals

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SLIDE
11 Support self-efficacy

• Self-efficacy is a person’s belief or confidence in their ability to carry out

a target behaviour successfully
• A general goal of MI is to enhance the person’s confidence in their ability
to overcome barriers and succeed change
• HCP can support self-efficacy by recognizing small positive steps that
the person is taking to change their behaviour
• Setting reasonable and reachable goals that the person can actually
accomplish will also help build confidence
• MI use the general concept of elicit-provide, which is a continuous
process. Information is elicited from the person so that HCP can better
understand their attitudes, belief, values and readiness to change
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
12 Eliciting statement supporting self-efficacy

• “It seems you have been working hard to quit smoking. That is different
than before. How have you been able to do that?”
• “Last week you were not sure you could go one day without cigarette,
how were you able to refrain yourself from smoking the entire past
week?”
• “So even though you have not been abstinent everyday this past week,
you have managed to cut down your smoking significantly. How were
you able to do that?”
• After asking about changes clients have made, it is important to follow
up with a question about how clients feel about the changes they made
• “How do you feel the changes you made?”

SLIDE
Motivational interviewing strategies
13
The practice of motivational interviewing involves the following strategies
1. Ask open ended questions
2. Affirmation
3. Listen reflectively
4. Elicit change talk
5. Summarise

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SLIDE
Motivational interviewing strategies 14
Ask open-ended questions
1. “What are your thoughts about setting a quit date?” (Open-ended) vs.
“Would you like to set a quit date?” (closed)
2. “Tell me about your cigarette use on a typical day?” (Open-ended) vs. “How
many cigarettes do you smoke on a typical day?” (closed)

Affirmation
1. “I think it is great that you want to do something positive for yourself.”
2. “That must have been very difficult for you.”
3. “That is a good suggestion.”
4. “I appreciate that you are willing to talk with me about your smoking
problem.”

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

Listen reflectively
• “You are not comfortable talking about quitting smoking at this time.”
• “You are surprised that your fagerstrom score shows you are severely
addicted to nicotine”
• “It is really important to you to smoke to maintain your body weight.”

Eliciting “change talk”

• “What would be some of the good things about cutting down on your
smoking?”
• “What do you think would work for you if you decided to quit smoking for
good?”
• “What worries you about your quitting smoking?”

Summarize SLIDE
15
“On the one hand, you enjoy smoking and you tend to smoke more when
you are with your friends. On the other hand, you have spent a lot more
money than you can afford on cigarette and that concerns you. You
are finding it difficult to pay your car loan and now your car had been
repossessed.”

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B. Model & Process Of Behaviour Change

SLIDE Behavioural Change Theories

16 1. Understanding why and how people make behavioural changes is key to
helping them modify their lifestyle in positive ways
2. There are many theories and models existed, and most original works
outlining the major theories were published in the 1970s and 1980s
3. Each theory or model focuses on different factors in attempting to
explain behavioural change
4. The most prevalent theories are:
a. Transtheorethical model of change
b. Social learning theories
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

c. Health belief model

d. The theory of reasoned action
e. The precaution adoption model

Transtheoretical Model (TTM) of Change

• Developed by Prochaska, DiClemente (1982)
• Based on an analysis of different theories of psychotherapy
• An integrative, biopsychosocial model to conceptualize the process
of intentional behavioural change
• Seeks to include and integrate key constructs from other theories into
a comprehensive theory of change that can be applied to a variety
of behaviours, populations, and settings (e.g. treatment settings,
prevention setting and policy-making settings, etc.)
• Consists of four “core constructs”:

Stages Process
of of Processes
change change of Change

Decisional Self
Balance
Decisional Self
balance efficacy

Stage

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General Concepts of the TTM of Change

• Bahavioural change is a “process involving progress through a series of
stages”, hence also called “the stages of change model”
• At each stage individual think and feel differently
• People are not all at the same stage of readiness when come to changing
behaviour or lifestyle factors
• While some are ready to begin the change itself, others may not even
aware why it might be important to change
• This approach begins with individual assessment of “readiness to
change” and customizes health intervention strategies based on their
stage
• The goal in this model is to move a person to the next stage

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
Stages of Change 17

The stages of change are as follows:

• Precontemplation stage (not ready)
• Contemplation stage (getting ready)
• Preparation stage (ready)
• Action stage Consolidation

• Maintenance stage
Action
• Relapse
Preparation

Centreplation

Pre-contempilation

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SLIDE
18
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
Spiral Model of the Stages of Change (1992)
19

SPIRAL OF CHANGE
Maintenance

Relapsed/
Recycle

Action
Relapsed/
Recycle

Relapsed/
Recycle Preparation

Precontemplation Contemplation

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Precontemplation SLIDE
20
• Not thinking seriously about changing or intending to change a problem
behaviour (or initiate a healthy behaviour) in the near future (usually
quantified as the next 6 months)
• They may be “in denial” about their problem behaviour, or not consider it serious
• Precontemplators are usually not armed with the facts about the risks
associated with their behaviour
• Additionally, many individuals make unsuccessful change attempts, becoming
discouraged and regressing back to the precontemplation stage
• Education on risks versus benefits and positive outcomes related to
change can trigger precontemplators to think seriously about changing

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

Contemplation SLIDE
21
• An individual enters the contemplation stage when he or she becomes aware
of a desire to change a problem behaviour (typically defined as within the next
6 months)
• In this stage, individuals weigh the pros and cons of changing their problem
behaviour
• Ambivalence between the pros and cons of change keeps many people
immobilized in this stage – hence called chronic contemplation or behavioural
procrastination
• Resolving this ambivalence is one way to help contemplators progress towards
taking action to change their behaviour
• Strong motivation can help contemplators to take decision to change

Preparation SLIDE
• By the time individuals enter the preparation stage, the pros in favour of 22
attempting to change a problem behaviour outweigh the cons.
• Intending to take action in the immediate future - typically measured as the
next 30 days
• Many individuals in this stage have made an attempt to change their behaviour in
the past year, but have been unsuccessful in maintaining the change
• Preparers often have a plan of action, but may not be entirely committed to
their plan
• Encouraged to seek support from someone they trust, tell others about their
plan to change the way they act, and think about how they would feel if they
behaved in a healthier way

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SLIDE Action
23
• Marks the beginning of actual change in the criterion behaviour, typically
within the past 6 months
• People in this stage are actively taking steps to change but have not
reached a point of stability.
• This is the point where relapse, and subsequently regressing to an earlier
stage is most likely
• People in this stage need to work hard to keep moving ahead
• They need to learn how to strengthen their commitments to change and
to fight urges to slip back
• Various techniques can be used to for keeping up commitments to
change, such as substituting activities related the unhealthy behaviour
with positive ones, rewarding themselves for taking steps towards
changing, and avoiding people and situations that tempt them to behave
in unhealthy ways
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

• Treatment programmes often starts here

SLIDE Maintenance
24
• People in the maintenance stage have achieved their initial goals and
are working to maintain gains and continue the change process until it
become permanent
• They have successfully attained and maintained behaviour change for at
least 6 months
• The stage in which people are working to prevent relapse and consolidate
the gain attained during action stage.
• They do not apply change processes as frequently as do people in action
stage
• They are less tempted to relapse and increasingly more confident that
they can continue their change
• People in maintenance constantly reformulate the rules of their lives and
are acquiring new skills to deal with life and avoid relapse
• They are able to anticipate the situations in which a relapse could occur
and prepare coping strategies in advance

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SLIDE
Relapse 25
• Along the way to permanent cessation or stable reduction of health behaviour
problems, most people experience relapse
• Relapse is an event and not a stage, may occur at any time
• More common to have at least one relapse than not
• Often involves regression from action or maintenance to an earlier stage
• For smoking only about 15% of people regress all the way to the
precontemplation stage – vast majority regress to contemplation or preparation
• Relapse is often accompanied by feelings of discouragement and seeing oneself
as a failure
• People who have relapsed need to learn to anticipate high-risk situations,
control environmental cues, and learn how to handle unexpected episodes of
stress more effectively

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
Stages and Description of the Change Model 25
• Not intending to change a behavior in the next 6 months
• Does not recognize that there is a problem
Precontemplation • Denies there is a problem
• Does not see the problem as serious

• Intending to change a behavior in the next 6 months

Contemplation • Recognize the need for behaviour change
• Is thinking about the pros and cons of changing the bahaviour

• Planning to change a behavior in the next 30 days

Preparation • Have made plan of action
• Experimenting with small pieces of the bahaviour change

• Making definitive changes in aspects of the behavior for less than 6

Action
months

Maintenance • Maintain new behavior for more than 6 months

• Full or partial return to previous behaviours

Relapse • Not a stage but an event
• Often accompanied by negative feelings

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SLIDE Quick Stage Assessment

26
Answer Yes or No
• Are seriously intending to change in the next 6 months
• Are you planning to change in the next month
• Have you tried to change in the past 12 months

Scoring
• Precontemplation : No to #1
• Contemplation : Yes to #1 and No to rest
• Preparation : Yes to all

SLIDE Stages of Change and Intervention Strategies

27
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

STAGE INTERVENTION STRATEGIES

• Encourage reevaluation of current behaviour

Precontemplation • Educate on risk - explain and personalize the risk

• Encourage evaluation of pros and cons of behaviour change

Contemplation • Identify and promote new positive outcome expectations

• Identify and assist in problem solving

Preparation • Help identify social support
• Encourage small initial steps

• Focus on restructuring cues and social support

Action • Bolster self-efficacy for dealing with barriers

• Provide encouragement and support

Maintenance • Reinforce internal rewards

• Evaluate trigger for relapse

Relapse • Reassess motivation and barriers

SLIDE Notes
28 • The stages of change address a facet of behaviour change ignored by many
other theories, namely that change is a process that occurs over time
• Change often comes at it’s own pace – often quickly and in burst, rather
than a consistent rate
• It should be noted that while progression through the Stages of Change can
occur in a linear fashion, a nonlinear progression is more common
• Most people will recycle through the stages of change several times before
the change becomes fully established
• Anything that moves a person along the continuum towards making a
positive change should be viewed as a success

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SLIDE
The Stages of Change Continuum (Adapted from Prochasca and DiClemente, 29
1998)

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE
Process of change 30
• While the stages of change are useful in explaining when changes in
cognition, emotion and behaviour take place, the processes of change help
to explain how these changes occur
• These are coping activities or strategies (covert or overt) used by people in
their attempts to change
• Each change process is a broad category of coping activities which
encompasses multiple techniques, methods and intervention
• There are 10 processes involved, and can be divided into two groups namely
cognitive and behavioural processes

SLIDE
Two Main Types of Change Processes 31
I. Cognitive change processes
Involve changes in the way people think and feel about their smoking

II. Behavioural change processes

Involve people making changes to their smoking behavior

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SLIDE The Ten Processes of Change

32
• Consciousness raising
• Dramatic relief
COGNITIVE PROCESS • Environmental reevaluation
• Self-reevaluation
• Social liberation

• Self-liberation
• Reinforcement management
BEHAVIORAL PROCESS • Helping relationship
• Counter-conditioning
• Stimulus control

SLIDE Consciousness Raising

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

32
1. Increasing information about self and the problem behaviour
2. Interventions that can increase awareness include observations,
confrontations, interpretations, and bibliotherapy
3. Examples :
a. Thinking about the health effects of smoking
b. A doctor asking whether you smoke
c. Thinking about how you are running out of breath
d. Reading a quit book
e. Watching media campaigns about anti-smoking

SLIDE Dramatic Relief

32
1. Experiencing strong emotional reactions to events associated to the
problem behaviour
2. Feeling fear, anxiety, or worry because of the unhealthy behaviours, or
feeling inspiration and hope when they hear about how people are able
to change to healthy behaviours
3. Examples :
a. Deciding to do something about your smoking after your father is
diagnosed with lung cancer
b. Seeing the effect of blowing smoke through a white handkerchief

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Environmental Reevaluation SLIDE

1. Combines both affective and cognitive assessments of how the target 33
behaviour affects one’s physical and social environment.
2. Realizing how their unhealthy behaviour affects others and how they could
have more positive effects by changing
3. Examples:
a. Thinking about the effects of smoking around the kids
b. Noticing cigarettes butts on the streets

SLIDE
Self Re-evaluation
34
1. Cognitive and affective re-experiencing of one’s self and problem
2. Realizing that the healthy behaviour is an important part of who they are
and what he/she want to be
3. Often involves weighing up the costs and benefits of changing the problem
behaviour to a healthier ones (e.g. smoking versus quitting )
4. Examples:

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

a. Thinking that you are no longer happy being a smoker
b. Imagining yourself being a non-smoker

SLIDE
Social Liberation 35
1. Realizing that society is more supportive of the healthy behaviour
2. Requires an increase in social opportunities or alternatives especially for
people who are relatively deprived such as
a. Advocating for rights of nonsmokers
b. Creating more smoke free areas
3. Examples:
a. Noticing the non-smoking areas around you
b. Joining a quit smoking course

Self Liberation
1. Believing in one’s ability to change and making commitments and re-
commitments to act on that belief
2. Comes with accepting responsibility for choosing to make changes and taking
the appropriate action
3. If a private commitment to oneself is then made public it creates social
pressures to support the change
4. Examples :
1. Telling yourself that you can quit smoking
2. Setting a quit day
3. Telling others you are quitting
4. Taking a pledge that you will quit smoking on the set quit date

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SLIDE Reinforcement Management

36
1. Continuing the reinforcement of positive benefits to change through
rewards
2. Contingency contracts, positive self-statements, praises and recognition
are procedures for increasing reinforcement and the likelihood that
healthier responses will be repeated
3. Examples:
a. The family showering you with praises
b. Buying yourself presents
c. Telling yourself how wonderful you are

SLIDE Helping Relationship

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

37
1. Combine caring, trust, openness and acceptance as well as support for the
healthy behavior change
2. Trusting others and accepting their support
3. Rapport building, a therapeutic alliance, counselor calls and buddy
systems can be sources of social support
4. Examples:
1. Asking a friend who used to smoked for help
2. Calling the quit line

SLIDE Counterconditioning
37
1. Positive alternative behaviours are substituted for the individual’s
problem behaviour
2. Any activity that distracts one thinking about, or craving for the problem
behavior is another way of counterconditioning such as engaging in
physical activity
3. Examples :
a. Relaxation to counter stress
b. Assertion to counter peer pressure
c. NRT to substitute for cigarettes

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Stimulus Control SLIDE

38
1. Avoiding or countering stimuli that elicit the problem behaviour
2. Environmental re-engineering and self-help groups can provide stimuli that
support change and reduce risk of relapse
3. Examples:
a. Cleaning up ashtrays before quit day
b. Avoiding bars and friends who still smoke
c. Putting up no smoking sign in strategic places

Relationship between Processes & Stages of Change SLIDE

38
i. Cognitive change processes help people to move through the early

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

stages of change.
i.e. from not thinking about quitting to deciding to quit
ii. Behavioural change processes help people to move through the later stages of
change.
i.e. from making a quit attempt to staying quit

SLIDE
Matching the processes with the stage of change 39

Precontemplation Contemplation Preparation Action Maintenance

Consciousness raising
Dramatic relief
Enviromental reevaluation

Self reevaluation

Social liberation
Self liberation

Reinforce Management
Helping relationship
Counter conditioning

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SLIDE
40 Identify the process (1)
• I recall information a doctor have given me on the benefits of quitting
smoking
• Warnings about the health hazards of smoking move me emotionally
• I begin to think that smoking is polluting the environment
• I get upset when I think about my smoking
• I notice that more and more nonsmokers are asserting their rights
• I tell myself I can quit smoking if I really want to
• I can expect to be praised by others if I don’t smoke
• I have someone who listens when I need to talk about my smoking
• When I am tempted to smoke, I think of something else
• I remove things from my home that remind me of smoking

Identify the process (2)

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

• I make a commitment to quit smoking totally

• I notice that the government is making it more difficult for smokers by
declaring more smoke-free areas
• I check the tar and nicotine level of every cigarette I smoke
• I feel good about myself when I reduced the number of cigarettes I smoked
everyday
• Hearing someone dies of lung cancer because of smoking scares me a bit
• I consider the notion that society’s health care cost would be less if many
smokers quit smoking
• I find that keeping my self busy helps me avoid smoking
• I avoid going to health exhibitions especially when it is about anti smoking
campaign

Identify the process (3)

• I realized that the management is making it more difficult for people to
smoke
• I took a pledge to quit smoking in two weeks time
• I bought myself an expensive wrist-watch with the money saved for not
smoking for the past 6 months
• I quickly brush my teeth soon after having my meal
• I avoid going to places where many people smoke
• I told my wife and children to bear with me if I behave rather strangely this
coming weeks because I am trying hard to quit smoking for the first time

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• I snap my wrist with a rubber band every time I feel the urge to light up a
cigarette
• I started to jog every other day and take plenty of fluid to remain
abstinence from smoking

Identify the process and stage (4)

• Watching a documentary film on TV about someone who is a heavy
smoker dying of lung cancer
• Downloading from the internet some pages about different ways to stop
smoking
• Declaring smoke free home
• Buying a small present for oneself for being able to abstain from smoking
for a month
• Learning relaxation skills to relief stress
• Avoiding going to places like bar and food stalls in order to remain smoke

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

free for another month
• Joining group therapy to quit smoking
• Switching to lower tar and nicotine cigarette in order to reduce harm

Identify the process and stage (5)

• Keeping a diary record of every cigarette smoked in order to know the
smoking pattern for a day
• Getting registered for smoking cessation programme
• Listening attentively to a talk given by a doctor regarding the benefits of
smoking cessation
• Telling family members about the decision to quit smoking for good
• Receiving medical test results showing that smoking is beginning to cause
real damage to health
• Weighing up the costs and benefits of smoking
• Arguing about the effects of smoking that lead to cancer
• Telling others that it is alright to smoke as long as smokers take plenty of
vitamins and exercise everyday to keep fit

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SLIDE Decisional Balance

41
• Decisional balance is the importance a person gives to the perceived
advantages (pros) and disadvantages (cons) of smoking and of quitting
• An individual’s motivation to change is affected by his/her decisional
balance
• Decisional balances changes across the stages of change
• Use of cognitive changes process can help tip the decisional balances in
favour of quitting

Decisional Balance Across the Stages of Change

(From Prochaska, Velicer, Rossi et al. 1994)
Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

SLIDE Self-efficacy
42
• Self-efficacy is a person’s confidence in his/her ability to quit, and to resist
temptations
• Confidence to resist temptations to smoke varies across the stages of
change, being lowest in Precontemplation and highest in Maintenance
• Self-efficacy is a strong predictor of success in the Action and Maintenance
stages

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Summary SLIDE
43
1. Behavioural change can be thought of as occuring as a progression through a
series of stages – the TTM calls this the Stages of Change
2. In general for people to progress, they need:
a. A growing awareness that the pros of changing outweigh the cons – the TTM
calls this Decisional Balance
b. Confidence that they can make and maintain changes in situations that tempt
them to return to their old, unhealthy behaviour – the TTM call this Self-
efficacy
c. Strategies that can help them make and maintain change – the TTM calls
these Process of Change

Enhancing Motivation to Quit Smoking Model and Process of Behaviour Change

How is the Model Useful? SLIDE
44
1. Provides a framework for understanding the process of how people change
2. Recognises that people in different stages of change need different types of
interventions to help them progress.

References SLIDE
45
1. Prochaska, J.O., DiClemente, C.C. & Norcross, J.C. (1992). In search of how
people change: Applications to addictive behaviors. American Psychologist,
47(9), 1102-1114.
2. Prochaska, J.O., Velicer, W.F., Rossi, J.S., Goldstein, M.G., Marcus, B.H.,
Rakowski, W., Fiore, C., Harlow, L.L., Redding, C.A., Rosenbloom, D., & Rossi,
S.R. (1994). Stages of change and decisional balance for twelve problem
behaviors. Health Psychology, 13(1), 39-46.

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