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Counseling is a vital part of the tobacco use treatment standard of care.(1) Counseling should be person-centered and trauma-informed. Counseling helps clients find their own motivation, discover ways to change old thoughts or patterns that no longer serve them, and develop new skills or patterns for relaxation, dealing with stress, and healing from trauma. For people with behavioral health conditions, concurrent treatment of tobacco use and their behavioral health condition enhances success for both.(2) Integrate tobacco use treatment into the behavioral health treatment that you already provide. Learn more about motivational interviewing, setting goals, evidence-based counseling strategies, group curricula, and quit guides below.
Evoking Client Reasons to Make a Change: Motivational Interviewing
Motivational interviewing is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence.(3) Everyone experiences ambivalence, and it often comes from the actions that we take that do not align with our values and the goals we set for ourselves. Very often, tobacco use conflicts with something else a client values such as: health, mental wellbeing, fertility, children or loved ones’ safety, appearance, personal freedom, or money. By exploring with genuine curiosity where someone feels ambivalent about tobacco use and non-judgmentally developing the discrepancy between what they value and using tobacco, counselors can support clients moves toward making a change. (3)
Commonly, this conversation is skipped during screening for tobacco use. Often clients are screened by being asked, “do you smoke?” if their answer is yes then they are asked, “are you ready to quit?” This will yield many “no” answers, because of ambivalence. It is not that clients are not interested in quitting, they usually feel ambivalent about quitting and ambivalence means there are reasons clients want to and do not want to make a change. Rather than asking a yes or no question, take the time to explore the role tobacco plays in clients’ lives. This will help them find reasons they have for quitting.
Here is a tobacco use conversation tool that can help you have a conversation individually or in a group with clients to help them explore their ambivalence: the reasons to stay the same and the reasons to make a change in their tobacco use.
It is important to avoid the righting reflex: the temptation to lecture clients about how their tobacco use conflicts with what you value, to correct misinformation, or to argue with clients about why what they are saying is incorrect. This naturally causes clients to dig in their heels and argue more strongly for all the reasons to not make a change. If instead you non-judgmentally reflect what the client has said, even if this does not take you in the direction you want to go, the therapeutic alliance with the client is not damaged by arguing or sending the client further away from making a change.
Here are some other strategies you can use to evoke change talk with clients, in addition to reflections:
Highlight discrepancies between values/beliefs and current behavior.
- “It sounds like _________ is really important to you. Tell me a little bit about how tobacco use fits in with ____________.
Reinforce change talk and commitment language.
- Listen for and reflect statements about desire, ability, reasons or need for change, and commitment, willingness, or steps taken toward change.
Help identify and build on past success.
- Ask about past quit attempts – what reasons did the person have for quitting in the past? What went well and what got in the way?
Offer smaller achievable steps toward change.
- Cutting back on tobacco use, making the home or car tobacco-free, staying tobacco free while at the program, experimenting on cutting down with medications
Acquire or sharpen your motivational interviewing skills by attending trainings through NC Area Health Education Centers (AHEC) or those listed by the Motivational Interviewing Network of Trainers (MINT).
Goal Setting and Making A Quit Plan
Tobacco use treatment goals can be anything from setting a quit date to simply tracking tobacco use to build awareness. Setting a quit date is a wonderful goal AND it is important to act on any motivation a client has to engage in evidence-based treatment for tobacco use in any way.(4) For example, clients can start counseling and medications without setting a quit date or they can set themselves up for future success by making the home or car tobacco free.
Set SMART tobacco use treatment goals. SMART goals are Specific, Measurable, Attainable, Relevant, and Timely. Setting a quit date could be a SMART goal. Here is an example of a SMART goal, each part of it is color coded to demonstrate each element:
To protect my kids from secondhand smoke, I will make my home tobacco free before I come in next week by removing all ashtrays, cleaning, and only smoking out on the sidewalk.
This goal is attainable and aligns with the client’s values’ they might not be ready to quit smoking but they are ready to protect their children. Or they might need to build up their confidence with a goal they find attainable and then come back to quitting.
Creating a quit plan sets clients up for success. Here are the elements of quit plan:
- Identify core reasons for quitting
- Decide on medications/access (useful to start medications two weeks before the quit date, to ensure clients can use them effectively and are getting relief.)
- Track your habit for at least one week
- Identify triggers
- Identify healthy alternatives to triggers
- Set Quit Date
- Identify social supports
- Prepare your environment (remove ashtrays, triggers, clean etc.)
Becoming tobacco free is more complicated than just substituting healthy alternatives to triggers, even the best plans are put to the test in stressful situations. Learn more about evidence-based counseling strategies to support clients with quitting below.
There is a strong dose-response relationship between time spent receiving counseling and success with quitting.(1) Face-to-face individual counseling has the best efficacy rate, followed by group counseling and telephone counseling.(1) Individual, group, and telephonic counseling are all evidence-based for tobacco use treatment.(1) You can learn more about telephone and web counseling available to all North Carolina residents through QuitlineNC. Here are some treatment modalities that are evidence-based for tobacco use treatment:
Acceptance and Commitment Therapy (ACT) is a therapy aimed at increasing psychological flexibility, identifying clients’ core values, and rather than avoiding unwanted thoughts or feelings to accept them as a part of life, while still remaining true to their values.(5) Being able to accept negative feelings or cravings to smoke without fighting them or acting on them helps them to pass more quickly. In North Carolina you can learn more about ACT and find training through ACT at Duke or through NC AHEC.
Cognitive Behavioral Therapy (CBT) is evidence-based practice that helps identify and change thought patterns that clients identify no longer serve them in reaching their goals.(6) If someone did not have a strong attachment relationship with a caregiver or has past trauma, an example of an unhelpful thought they might have is: “I am unlovable.” This belief that the person is unlovable can be a source of shame and sadness. It makes tough emotional situations much worse and can set that person up to smoke in order to do away with those negative feelings. CBT can help clients to interrogate those thought patterns, look at the evidence, and come up with positive thought patterns that help them reach their goals. Learn more about CBT and find training through NC Area Health Education Centers (AHEC).
Mindfulness Based Interventions (MBIs) Mindfulness is paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.(6) Mindfulness training can help reduce negative emotions and stress and help with relaxation.(6) Mindfulness aims to increase nonjudgmental awareness and acting with purpose, which are useful skills when dealing with cravings for tobacco. Learn more about mindfulness based interventions from NC AHEC or check out University of North Carolina Wilmington’s Certificate in Mindfulness program for healthcare providers.
Group Curricula, Workbooks, and Quit Guides
Here are some of the most useful evidence-based resources or curricula to help you start your own tobacco use treatment group.
Freedom from Smoking, American Lung Association
Breathe Easy, Live Well wellness group, including tobacco use treatment, for people with severe and persistent mental illness
NJ Learning about Healthy Living designed to be led by peers, consumers helping other consumers
BecomeAnEX is a website where people can make a quit plan and receive support in their quit attempt from an online community. The content was created by former smokers. Become An Ex also created useful workbooks in English and Spanish that you can give to clients or use in a group.
The Million Hearts Tobacco Cessation Change Package– A comprehensive guide to implementing tobacco use treatment in your health system.
- US Department of Health and Human Services. Treating Tobacco Use and Dependence: 2008 Update [Internet]. Rockville, MD: US Department of Health and Human Services; 2008 [cited 2021 Jun 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK63952/
- Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annual Review of Public Health [Internet]. 2017 Mar 20 [cited 2021 May 18];38:165–85. Available from: https://pubmed.ncbi.nlm.nih.gov/27992725/
- Lindson-Hawley N, Thompson TP, Begh R. Motivational interviewing for smoking cessation [Internet]. Vol. 2015, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2015 [cited 2021 Jun 15]. Available from: https://pubmed.ncbi.nlm.nih.gov/25726920/
- Greenberg MR, Greco NM, Batchelor TJ, Miller AHF, Doherty T, Aziz AS, et al. Physician‐directed smoking cessation using patient “opt‐out” approach in the emergency department: A pilot program. Journal of the American College of Emergency Physicians Open [Internet]. 2020 Oct [cited 2021 May 19];1(5):782–9. Available from: https://pubmed.ncbi.nlm.nih.gov/33145519/
- Singh S, Starkey NJ, Sargisson RJ. Using SmartQuit®, an Acceptance and Commitment Therapy Smartphone application, to reduce smoking intake. DIGITAL HEALTH [Internet]. 2017 Jan [cited 2021 Jun 15];3:205520761772953. Available from: /pmc/articles/PMC6001237/
- Spears CA, Hedeker D, Li L, Wu C, Anderson NK, Houchins SC, et al. Mechanisms underlying mindfulness-based addiction treatment versus cognitive behavioral therapy and usual care for smoking cessation. Journal of Consulting and Clinical Psychology [Internet]. 2017 Nov 1 [cited 2021 Jun 15];85(11):1029–40. Available from: /pmc/articles/PMC5662477/