Counsellors' Manual for Commercial Tobacco Cessation Treatment

IT’S TIME: INDIGINENOUS TOOLS & STRATEGIES ON
TOBACCO INTERVENTIONS & MEDICINES
Counsellors’ Manual for
Commercial Tobacco
Cessation Treatment
This is an optional, supplementary resource for counsellors, community
workers and peer helpers who are able to provide counselling sessions
to groups or individuals trying to quit commercial tobacco use.
This manual uses a combination of motivational interviewing and
cognitive behavioural therapy approaches, and can be offered to either
groups or individuals. Note that the tools and materials in this resource
may not be relevant or helpful to all people – this resource is one among
many approaches to healing and recovery from commercial tobacco use.

NICOTINE DEPENDENCE CLINIC, CAMH
© Centre for Addiction and Mental Health
2011
This resource may be freely reproduced, adapted and used by any helper or community in accordance with OCAP principles
(Ownership, Control, Access and Possession).

Session
1
Screening and Assessment
This session is designed to give people personalized feedback about their
tobacco use and how it is affecting other areas of their lives. An emphasis is
placed on ensuring that assessment information is used clinically to enhance a
person’s motivation and readiness to change.
T
obacco dependence can be a challenging topic to raise with people, particularly when they
are seeking help for some other issue. Even opening a conversation about commercial
tobacco use can be a challenge if the person has been accustomed to being “lectured” by
health practitioners, family, friends and the media. Adopting a motivational stance is
important in raising the issue in a non-confrontational, matter-of-fact way. This means:
Avoiding arguing
Expressing empathy
Developing discrepancies between a person’s goals and their use of commercial tobacco
Rolling with resistance
Supporting self-efficacy (confidence that they can achieve their goals).
For example, asking the person, “What is the most unusual thing you’ve ever done to make sure
you’d have cigarettes for the next morning” can elicit responses that are very helpful in
developing a discrepancy between how a person regards him- or herself, and his or her behaviour.
Examples we have heard in our practice include ordering pizza in order to get cigarettes delivered,
picking cigarettes off the ground, stealing and sifting through cigarette butts in an ashtray. The
important thing is to give people an opportunity to explore and resolve their ambivalence around
changing their use of commercial tobacco. Helpers should strive to avoid attempts to persuade or
confront people about their tobacco use, as this can lead to resistance and disengagement.
The tools in this section can be used in a variety of ways:
Brief screening tools used in conjunction with other intake or assessment instruments in
your program or service

As a standalone brief assessment of commercial tobacco use
As a more structured follow-up to a short conversation about commercial tobacco use
As the first session in a group or individual treatment program for commercial tobacco
cessation.
As a helper, you are the best one to decide – in partnership with your client – how to approach
the topic of commercial tobacco use, what kinds of questions to ask, what kinds of structured
tools to use, and how to build a trusting relationship. In the end, it is the relationship between
helper and client that is the most vital. The tools in this section and throughout this manual are
meant to support an exploration and journey towards healing and recovery, so use or adapt what
is useful and leave the rest.
Note that many of the tools and approaches discussed in this manual have been used with other
kinds of substance use or behaviour change issues – most of them are not specific to commercial
tobacco use (especially the tools in Sessions 2-6). There are some references at the end of this
manual if you would like to access further readings or resources on motivational interviewing,
cognitive behavioural therapy and health behaviour change.
Session 1: Assessment
Clinical Tools
‣ Fagerstom Test for Nicotine Dependence
‣ How does commercial tobacco affect you and others in your life (worksheet)
‣ Brief Commercial Tobacco Use Assessment form
‣ Reasons to Quit Smoking form and Why You Smoke Commercial Tobacco form
A NOTE ABOUT CALCULATING “PACK YEARS”:
The simple formula for calculating pack years is as follows:
# of cigarettes / day X # of years smoked
__________________________________
20
=
___ pack years
For example, a person who smokes 25 cigarettes per day for a total of 35 years would have a 43.75 pack year history (25 x 35 =
875; 875 ÷ 20 = 43.75). An online pack year calculator, frequently asked questions and correlations between pack years and
smoking related diseases can be found at: http://smokingpackyears.com/.
One of the utilities of this tool is to help determine which people might be referred for spirometry screening which helps detect COPD
(cardio-obstructive pulmonary disease). People with a pack year history of 15 or more, especially those over age 40, should be
referred for this type of screening. (Tinkelman et al., 2007).
Tinkelman, D.G., Price, D.B., Nordyke, R.J. and Halbert, R.J. (2007). COPD Screening efforts in primary care: What is the yield
Primary care Respiratory Journal, 16 (1), 41-48.
3

Fagerstrom Test for Nicotine Dependence
Not only is it important to know whether or not your patients smoke, it’s also important to know
how addicted to nicotine they actually are. Fagerstrom’s Test for Nicotine Dependence is an easy
way to assess your patient’s addiction. Have your patients answer the questions; each answer gets
a set amount of points. Add up the points and check out the score indicator below:
Questions Answers Points
1. How soon after you wake up do you smoke your
first cigarette
2. Do you find it difficult to refrain from smoking
in places where it is forbidden such as church, the
library, or movie theatres
Within 5 minutes
6 to 30 minutes
31-60 minutes
After 60 minutes
Yes
No
3
2
1
0
1
0
3. Which cigarette would you hate most to give up The first one in the morning
All others
1
0
4. How many cigarettes do you smoke (20
cigarettes are
in a pack)
5. Do you smoke more frequently during the first
hours after waking than the rest of the day
6. Do you smoke if you are so ill that you are in
bed most of the day
10 or less
11-20
21-30
31 or more
Yes
No
Yes
No
0
1
2
3
1
0
1
0
Score:
0-2 Very Low Addiction
3-4 Low Addiction
5 Medium Addiction
6-7 High Addiction
8-10 Very High Addiction
Usually, people who score 6 or greater need additional assistance in quitting smoking. This may
mean Nicotine Replacement Therapy or one-on-one counseling to problem solve ways to
overcome barriers and cope with withdrawal symptoms.
This information is provided by WHISC - Women’s Health: Interventions for Smoking Cessation. It is part of the Provider Tool Kit for Assisting
Women to Quit Smoking. WHISC is a project funded by a grant from The Duke Endowment to Wake Forest University School of Medicine in
partnership with the Northwest AHEC (North Carolina) Program. January 2001
4

How does commercial tobacco affect you and
others in your life
PHYSICAL
SPIRITUAL
Example: I have a cough
especially in the mornings
Example: Tobacco is a gift from the
Creator, and I want to honour that gift
Example: Feeling bad because I want
to set a good example for my kids
Example: Thinking about how smoking
cigarettes is hurting my body
EMOTIONAL
MENTAL
5

BRIEF COMMERCIAL TOBACCO ASSESSMENT FORM
I. CURRENT COMMERCIAL TOBACCO USE
Number of
Cigarettes/
day
Importance
Fagerstrom
Test for
Nicotine
Dependence
Confidence
/10
# of cigarettes / day X # of years smoked
__________________________________
20
=
___ pack years
/10
Readiness to
Change
/10
Goals around Commercial Tobacco Use
Cessation Reduction Undecided
Commercial Tobacco Use History
Age smoking started ________________ Number of past quit attempts______________
Most recent quit attempt _________________ Longest quit (number of) ___________ months
What led to relapse _____________________________________________________________
Past quit smoking strategies ______________________________________________________
II. COMMENTS
III. SMOKING ENVIRONMENT
Exposure to 2nd hand smoke on a regular basis______________
OTHER COMMENTS ON ENVIROMENT (where you smoke, who you smoke with, etc)
IV. CURRENT MENTAL HEALTH ISSUES AND CURRENT TREATMENT
V. CURRENT MEDICAL CONCERNS AND CURRENT TREATMENT
6

VI. PAST MEDICAL AND/OR MENTAL HEALTH ISSUES AND PREVIOUS
TREATMENT
VII. OTHER SUBSTANCE USE
PRESENT USE
PAST USE
VIII. PSYCHOSOCIAL RELATIONSHIPS
(Include information on finances, employment, relationships/ support system, family, legal issues, current
stressors)
IX. TREATMENT PLAN
Include information on strengths and resources, traditional healing approaches, other helpers or resources
in the community, and any referrals needed to other programs (if available).
7

Why You Smoke Commercial Tobacco
This scale helps us identify some of the reasons or factor as to why you smoke. If you score higher in some
categories, then these might be the areas that you really need to focus on when you are trying to quit or reduce
your smoking. The higher the number in each category, the more likely that is an area is a factor for why you
smoke.
Stimulation _____ wake yourself up, give yourself some energy
Handling _____ like the feel of cigarette in hand, ritual of lighting cig.
Pleasure _____ your reward, smoke in pleasant moods or to celebrate
Coping _____ to cope with negative emotions or stress or trauma
Craving _____ experience physical craving or strong desire to smoke
Habit _____ specific routines, i.e.: after meals, with coffee, in car
Reasons To Quit
This scale will help you identify some of the reasons that are motivating you to quit. It is divided into 3 broad
categories: External (Others want you to quit, financial reasons), Self Image (worried about how cigarettes
make you look and feel about yourself) and Health (worried about current and future health). Again the
higher the score the more likely that is one of the reasons for why you would like to quit or reduce your
smoking
External Self Image Health
Opinion of others
Personal Appearance
Images of Illness
_________________
Financial Reasons
_________________
Environmental Factors
_________________
_________________
Responsibility
_________________
Self-Esteem
_________________
_________________
Health deterioration
_________________
Health Improvement
_________________
8

2
Strategize: What are my
reasons for change
Session 2 is designed to build on the momentum generated during the
assessment. This session is focused on facilitating an exploring a person’s
ambivalence about changing their use of commercial tobacco.
W
hy change This is a recurring question – and concern – for people considering any
change. This session poses the question of why changing commercial tobacco use
might be an important (and desirable) step towards accomplishing other life goals.
For example, the person may want to improve overall health, set a good example for
their children, or save money. On the other hand, we also recognize that there are powerful
reasons why a person might resist changing: concerns about weight gain, withdrawal symptoms,
coping strategies and losing the enjoyment of smoking are all factors that make it difficult to quit
commercial tobacco use. By using a combination of providing neutral information/feedback and
facilitating an exploration of ambivalence, this session helps build motivation.
Providing information in a motivational way can be a challenge. The temptation is to adopt a
warning or lecturing posture in communicating health effects or reasons for change. The danger
in this stance lies in the fact that it does not leave the person space to articulate his or her most
compelling reasons for change. Here are some tips for providing information more
“motivationally”:
1. Ask permission: Preface your comments with a statement such as, “I’d like to take the
next few minutes to go over some of the myths and facts about smoking. How does that
sound to you” This invites “conversational consent” from the person or group, and sets
the stage for a more productive discussion. An alternative “permission question” could be
something along the lines of, “Would it be helpful to briefly go over some of the longer
term risks associated with smoking as few as 10 cigarettes per day” It is often the case
that a person comes to counselling with a wealth of information already. Asking
permission respects the possibility that a person may already know what we are going to
tell them!
2. Provide the information in a neutral, non-dramatic way: It is hard to overstate the
risks of smoking cigarettes. However, by maintaining neutrality when we provide
information we acknowledge that people may choose to disregard our teachings…and in
the end, a decision to change can only be made by the individual. It is always better for
the client to express surprise, concern or dismay than for the helper to do so.

3. Beware of overloading a person with too much information: The handouts included
in this section are designed to be read by the person, and discussed in the group or the
individual counselling session. It is helpful to touch on key points or questions, and use
these as “jumping off” points for discussion and reflection.
4. When finished providing information, ask “How does that fit for you” or “What
do you make of that” These questions give a person the opportunity to reflect on how
(or whether) the information provided relates to his or her own life, experiences and
goals.
It can be also be useful to have a person reflect on their feelings and expectations about
counselling. For example, many people who have never attended group counselling may be
anxious about the amount or type of disclosures that are expected. An important task in building
cohesion in group treatment contexts is to teach people how to be “good group members”,
through modeling and feedback. Here are some sample questions to start a discussion of group
process issues, as well as build group cohesion:
“What was it like for you to sit in this circle”
“What are some of the things you are wondering about this group”
“What needs to happen here in order for you to feel like this is a really helpful
experience for you”
“What would be important for us to do to support each other”
“What are some ground rules or guidelines we should adopt in this group in
order for everyone to feel respected and safe”
The above questions can also be modified for use in individual sessions, in order to build rapport
and trust. Setting a supportive tone and fostering a psychologically safe climate are crucial in
counselling. Encouraging group members to interact with one-another (as opposed to directing all
communication through the helper), periodically pausing to reflect on group process (as opposed
to a strict content focus), and being explicit about group norms, goals and patterns of interaction
can all help foster cohesion and mutual support.
A client and a helper can work together to develop a strategy that mobilizes existing support
systems, coping strategies, and medicines (both traditional and non-traditional). Even before
setting s quit date, a person should be encouraged to begin to implement such strategies as:
• Keep track of when and how many cigarettes smoked, including thoughts and feelings –
this helps identify risky situations and possible triggers.
• Thinking about and talking about the costs and benefits of quitting versus continuing to
smoke commercial tobacco.
• Completing a Decisional Balance exercise and reflecting on the costs and benefits of
quitting versus continuing to smoke.
10

Session 2: Dealing with ambivalence
Clinical Tools
o Reasons for Change form
o Decisional Balance form
o Readiness Ruler
o
Traditional Alternative to Readiness Ruler: TOBACCO CESSATION MEDICINE WHEEL - AN ANISHNAWBEK
APPROACH
o Daily Diary – NOTE: You might find it helpful to make several copies of the Daily Diary, and encourage a
person to complete this every week, for discussion during each counselling session.

Reasons for Change
Making a commitment to meeting your goal is important to your success. Sometimes, it’s
easy to forget why you’re making the change, so write down your reasons and use this as a
reminder to yourself when things seem tough!
The most important reasons that I want to change are:
1. _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. _______________________________________________________________
_______________________________________________________________
_______________________________________________________________
12

Decisional Balance Sheet
Try to fill out personal reasons for why you continue to smoke commercial tobacco or why you may want to quit.
Benefits of:
Continue Smoking
o Reward
o Helps getting started in the morning
(routine)
o Helps me deal with stress
Quit Smoking
o Feel better about myself
o Set a good example for children and
community
o Save money
Costs of:
o Smells bad
o Costs too much
o Skin damage
o Out of breath when I walk
o It will be hard to quit
o I will miss smoking
o Other people might not support me
wanting to quit
13

Readiness Ruler
Now that you have thought about some of your reasons for change, where would
you rate the importance of actually making these changes How confident do
you feel about whether you can make this change How ready are you to start
the journey of change
How important is it to change this behaviour
How confident are you that you could make this change
How ready are you to make this change
14

TOBACCO CESSATION MEDICINE WHEEL
AN ANISHNAWBEK APPROACH
YOUR HEALTH & WELL-BEING - IT’S UP TO YOU!
10
MENTAL ASPECT
OF QUITTING TOBACCO
eg: poor judgment/decision making, difficulty
concentrating, bipolar illnesses, depression, etc.
How confident are you that you could make this change
PHYSICAL ASPECT OF TOBACCO USE
SPIRITUAL ASPECT OF QUITTING
TOBACCO
10 How has your tobacco use impacted you
How has quitting in the past affected you
0
eg: confusion, loss of
connectedness, and/or
problems in the physical,
emotional or mental aspects.
10
How ready are you to make this
change
EMOTIONAL ASPECT
OF QUITTING TOBACCO
eg: low self-esteem, loss of ability to
cope, relationship difficulties, etc.
How important is it to change this behaviour
10
Anishnawbek teachings maintain that a person contains the four directions which must be in balance to achieve health. This wheel is
combination of these teachings and the work of the TEACH project and motivational interviewing.
The numbers serve as a guide to help the person(s’) explore change and gives the helper an idea of the balance of the person(s)
The Gifts of the Seven Grandfathers (which are interwoven into daily life) are given to the people to help them understand and attain health and
well-being.
15

Daily Diary
Date
Behaviour
(How many
cigarettes
today)
Describe the situation (eg. Were
you alone or with others, at home in
a social setting)
Thoughts and Feelings (What
were you thinking and feeling in
this situation)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
16

3
Strategize: Setting a Quit Date
Session 3 is focused on working with people around making a decision to
change. Although not everyone may be ready to set a quit date or make a clear
decision, the session content can be adapted to continuing the work around
addressing ambivalence (Session 2).
M
aking a decision to change can be an intimidating process, particularly when it involves
giving up a long-term behaviour, such as smoking commercial tobacco. Therefore, the
emphasis on this session is to continue to build motivation by focusing on the tools
and strategies that can be helpful in changing commercial tobacco use. For some
people, the decision to change may involve cutting down (as opposed to quitting). For many
people, this is the most realistic first step, and harm reduction is a step in the right direction. In all
cases, the feasibility and reasonableness of a person’s goal should be addressed.
For a person who is not yet ready to change their use of commercial tobacco, the focus on this
session can remain on barriers to change, as well as possible strategies for overcoming those
barriers. A goal statement for someone not ready to quit might focus on a goal to smoke outside
to prevent other people and animals in the home from the effects of second-hand smoke. If
smoking is a way to cope with stress, the person’s goal might be to first try one or two other
useful strategies for stress management before having a cigarette, and noting how helpful these
alternative strategies are.
Nicotine replacement medications (such as the nicotine patch, gum, lozenge or inhaler) can also
be discussed in this session, and can be introduced as an option for anyone who is interested,
regardless of their willingness or perceived ability to set a change goal at this time.
A person completes the Goal Statement and another Readiness Ruler in this session. Note that an
interim goal (such as smoking outside or cutting down on the number of cigarettes smoked) may
be set if the person is not ready or willing to set a quit date at this time.
It is also helpful to explore traditional healing approaches: for example, healing circles, prayer,
offerings to the creator, teachings from an Elder, fasts or sweats can be powerful ways to support
and heal a person in his or her recovery.

Session 3: Making a Decision to Change
Clinical Tools
o Preparing for Quit Day handout
o How Fast Will I Improve Handout
o What withdrawal symptoms can I expect Handout
o Quitting Cold Turkey versus Cutting Down (handout)
o Myths and Facts of Nicotine Replacement Therapies Quiz
o Goal Statement & Readiness Ruler
Note that there are many handouts and tools in this
section – talk to your client about which one(s) would be
the most helpful.
18

Preparing for Quit Day
A few weeks prior to quit day, limit your smoking to only one room in your home or
completely make it smoke free. This room should be the least comfortable room in
your house.
Clean out your car and clean / deodorize your home.
Visit your dentist to get your teeth cleaned. With the tar and nicotine removed from
your teeth you are literally starting with a fresh mouth.
Monitor alcohol and caffeine consumption before and after quit date as these can been
seen as triggers to use. Cut down on caffeine after you quit, because people who don’t
smoke commercial tobacco are more sensitive to caffeine (for example, coffee will
have a stronger effect after you quit smoking).
Get lots of rest leading up to your quit day.
Drink lots of fluids as this can help with cravings.
Use healthy substitutes such as sugarless gum, carrot sticks, sunflower seeds, raisons
etc. This will help keep your mouth stimulated.
Repeat your reasons for quitting or post a list on your fridge where you will be
constantly be reminded.
Plan activities for your first week of being smoke free. Keeping yourself occupied is
important as well as planning activities that do not place you in situations where you
will be tempted to smoke.
Occupy your hands with toothpicks, pencil, rubber bands, stress balls, etc…
Be aware of cigarette advertisements or other triggers.
Never allow yourself to think that one cigarette won’t hurt. Many smokers relapse
when they believe they can control their smoking. This is harmful because even if you
are able to control your cigarette consumption for awhile it generally ends up
increasing to where it was before you quit.
Use your support system and don’t be afraid to ask for help from community members,
Elders, family etc.
19

How fast will I improve after I stop using commercial tobacco
Everyone improves after quitting smoking at varying rates. This may be dependent on amount smoked,
years smoked, if you are exposed to second hand smoke (among other factors).
Immediately
The air around you and your family and friends is safer.
Within 20 minutes of
last cigarette
After 8 hours
Blood pressure drops
Pulse rate drops to normal
Body temperature of hands and feet increases to normal
Carbon Monoxide level in blood drops
After 24 hours
Chance of heart attack decreases
After 48 hours
Nerve endings may re-grow
Ability of smell and taste enhanced
After 72 hours
Bronchial tubes relax; if undamaged, will make breathing easier
Lung capacity increases
2 weeks to 3 months Circulation improves
Walking becomes easier
Lung functioning may increase up to 20%
1 – 9 months Coughing, sinus congestion, fatigue, shortness of breath may decrease
Potential for cilia in lungs to re-grow, increasing ability to handle mucus, clean
the lungs and reduce infection
1 year The risk of heart disease is reduced by half of someone who continues to smoke
20

2 years Cervical cancer risk reduced compared to people who continue to smoke
Bladder cancer risk halved compared to continuing smokers
5 – 15 years Stroke risk is reduced to that of a nonsmoker!
10 years Risk of cancer of the lung, mouth, throat, esophagus, kidneys and pancreas
decreases
Document prepared by CAMH Nicotine Dependence Clinic – adapted from:
http://www.quittobacco.org/whyquit/physicalbenefits.html
21

What Withdrawal Symptoms Can I Expect
Each individual can experience very different withdrawal symptoms from quitting commercial tobacco. Most
people will experience the worst physical withdrawal symptoms within the first 3 – 5 days. If a symptom
persists or seems worse you should see a doctor or nurse practitioner. Here are some things you may
experience when quitting commercial tobacco use (cigarettes or smokeless tobacco).
‣ Occasional dizziness – This is caused by the fact that you are now absorbing more oxygen through
your lungs. The dizziness may come upon you for a few days and usually lasts for only a few
seconds.
‣ Headache – One in four smokers reports a mild headache at some point during their quitting
process.
‣ Hunger – Almost all smokers notice this symptom. Nicotine is an appetite suppressant so you feel
like eating more. The body’s absorption of food is improved too, so that you gain more nourishment
even if you do not actually increase the amount you eat. It is important to note that not all people
gain weight when they quit and healthy eating and exercise can help to curb this.
‣ Constipation – Intestinal motility may decrease for a brief period when you quit cigarettes. This
usually lasts for only 3 – 4 days. If you have further concerns about this please see a health
practitioner.
‣ Shakiness – You may notice your hands tremble slightly, perhaps for several weeks. The tremor
usually subsides as your body gets used to its new non-smoking environment.
‣ Sweating – This is another common reaction. Like the shakes, it will go away after a while. Hot baths
or showers can dispel the perspiration.
‣ Coughing more – As the cilia in your lungs rebuild, they start to clean the bronchial tubes and
remove the phlegm, thus causing increase in coughing. This can last for a few weeks and results in
the disappearance of the “smoker’s cough”.
‣ Other symptoms you may experience include: decreased concentration, feeling fatigued,
nervousness, irritability, anxious, or sadness. These are normal, and they are part of physical,
emotional and spiritual healing from commercial tobacco.
22

Cold-Turkey vs. Cutting Down
We are often asked which strategy is the best way for quitting commercial tobacco use. Unfortunately there
is no easy answer and this decision depends on each individual’s preferences, strengths and weaknesses.
Consider the following information before making your decision.
Cold-Turkey
When a person quits cold turkey this means that he/she has gone from smoking his/her normal amount of
cigarettes to abruptly stopping completely. The amount of nicotine in blood stream quickly drops off. As a
result, the body may experience some withdrawal symptoms (restless, irritable, appetite changes, sleep
disturbances, headache, fatigue, coughing etc.). The benefit of quitting this way is that it is quick and your
body begins to heal itself immediately.
Cutting down or tapering
Some people decide to cut down the number of cigarettes that they smoke and thereby reduce the amount
of nicotine in the body. The benefit to this process is the potential reduction of withdrawal symptoms.
However some people find that it is difficult for them to maintain a lower level of nicotine because the body
begins to crave the original amount that the smoker was consuming. Therefore they may find themselves
going up and down with the amount that they smoke because the body may experience mini withdrawal
symptoms. To prevent this from happening nicotine replacement therapies were developed. These
products were designed to lower the amount of nicotine in the body gradually to minimize withdrawal.
Whatever method of quitting you decide upon, it is important to be prepared. If you decide to go coldturkey,
know what you are going to do on your quit date and have supports in place to help you through
your chosen date. Alternatively, if you are going to taper down, there are many strategies that you can use to
help you through this process.
23

Myths and Facts about stop-smoking medications
How much do you know about medications to help people quit smoking Take
this True-or-False quiz and find out (answers are at the bottom).
Myth or Fact
1. Nicotine is one of the harmful substances in cigarettes.
2. Nicotine addiction is equally likely whether the nicotine is obtained
from cigarettes, nicotine patch, gum, lozenge or inhaler.
3. Nicotine patches, gum, lozenge and inhalers carry significant health
risks if used by people who smoke.
4. Smoking while on the patch causes heart attacks.
5. People with heart disease should not use nicotine replacement
medications.
6. Pregnant women should never use nicotine replacement
medications.
7. People under age 18 should never use nicotine replacement
medications.
8. Stop-smoking medications should not be used in combination with
one-another.
9. People using nicotine replacement medications should not exceed
the dose recommended on the medication package.
10. Stop-smoking medications are only appropriate for short-term use.
11. Nicotine replacement medications should not be used by people
who just want to cut down on the number of cigarettes they smoke.
True or False
Answers:
1. False: The thousands of toxins in tobacco smoke are harmful. Nicotine is not associated with cancers or chronic respiratory conditions.
2. False: Cigarettes are far more addictive than nicotine replacement, primarily because of how they deliver nicotine.
3. False: Nicotine replacement therapy is safe for smokers.
4. False: The use of nicotine replacement does not increase cardiovascular risk,
5. False: It is more dangerous for people with heart disease to continue smoking than to use nicotine replacement, and many such patients are not able to
quit on their own.
6. False: nicotine replacement is safer for the fetus than smoking, and is appropriate for pregnant women who are unable to quit using behavioural
interventions.
7. False: Most daily smokers begin smoking before age 18, and are already getting nicotine from cigarettes. Nicotine replacement should be considered for
youth who are regular smokers who are unable or unwilling to quit using behavioural interventions.
8. False: The nicotine patch/gum/lozenge/inhaler can be used at the same time and/or in combination with bupropion (Zyban).
9. False: Smokers should be in control of how and how much they use nicotine replacement medications.
10. False: Nicotine replacement should be used for as long as needed to maintain or prolong tobacco abstinence.
11. False: Nicotine replacement can be used by people who are not ready to quit as a way to reduce their smoking, and progress towards a longer-term
goal of abstinence.
(adapted from Ontario Medical Association Position Paper: Rethinking stop-smoking medications: Treatment myths and medical
realities, January, 2008).
24

Goal Statement
The behaviour I want to/need to change is:
_____________________________________________________
_____________________________________________________
_____________________________________________________
What is your goal now
_____________________________________________________
_____________________________________________________
_____________________________________________________
Start date: ______________________________
Achievement date: _______________________
Tip – If you are not ready to quit commercial tobacco, think about what a small goal
might be. One example might be to not smoke in your car, to smoke outside, or to not
smoke for a three hour period each day for a week. Any others
25

Readiness Ruler
Now that you have set a goal, where would you rate the importance of you goal
How confident do you feel now in accomplishing your goal How ready are you
to continue the journey of change After you have completed this sheet, go back
and compare your responses with the one you completed in the last session.
How important is it to change this behaviour
How confident are you that you could make this change
How ready are you to make this change
26

4
Take Action
Session 4 builds on the person’s goal statements by asking him or
her to identify what might stand in the way of accomplishing these
goals. In Session 4 we are asking people to examine their major
risk situations for commercial tobacco use. The work in this session
sets the stage for the development of concrete plans for preventing
relapse, covered in Session 5.
I
dentifying high-risk situations is an important step towards being able to develop
a way to deal with triggers to use commercial tobacco. This session is focused on
a detailed look at the person’s major areas of risk. It can be a challenge for a
person who uses commercial tobacco in so many different settings and
circumstances to come up with three major triggers…especially in the early days and
weeks of quitting or cutting down tobacco use. However, the process of figuring out
the states of mind, settings, times of day or other triggering events is key to coming up
with an effective coping plan. Even opening the conversation gives a person some
“food for thought” around beginning to anticipate – and plan for – the situations that
will be especially difficult.
Here are some suggestions of common risk situations to get the conversation started:
First thing in the morning, or just before going to bed
After meals
While driving
With a coffee
While on the phone
In a social setting
With particular people (friends or family members)

When feeling upset, sad or angry.
The discussion of triggers is complemented in this session by also focusing on possible
coping strategies. Important messages to reinforce are that change is possible, and even
the most severe cravings will pass.
For example:
Changes in mood = what further support is needed
Withdrawal symptoms = re-assess medicines or think about using nicotine
replacement
Low motivation = review Decisional Balance and Reasons for Change exercises
Weight gain = recommend physical activity, healthy eating, additional support
Lapses or slips = explore triggers and coping strategies; continue self-monitoring
Perhaps most important of all, especially if the person has been experiencing some
difficulties in meeting his or her goal, is to congratulate him or her for coming back to
see you, and for the effort of trying. Remind the person that quitting smoking is not an
event, it is a process!
In this session, it is suggested that you complete with the person the Triggers and
Consequences work sheet and/or the Change Plan Work Sheet.
28

Session 4: Making a Decision to Change
Clinical Tools
o Triggers and Consequences Worksheets
o Change Plan Worksheet
o General Coping Strategies (handout)
o Healing from Commercial Tobacco Use – Some Traditional Approaches (handout)
Note that there are many handouts and tools in this section
– talk to your client about which one(s) would be the most
helpful.

Triggers and Coping Skills
Sample Plan
Triggers
Coping Skills
Smoke with friend every
day at breaks
Tell friend “I am quitting”
After meals
Chew gum after meals; get up
from table right away
Stress at work gets too
much on some days
Plan to take walks when
stress is high
Triggers
Coping Skills
30

Change Plan Worksheet
The changes I want to make are:
________________________________________________________________________
________________________________________________________________________
The most important reasons why I want to make these changes are:
________________________________________________________________________
________________________________________________________________________
The steps I plan to take in changing are:
________________________________________________________________________
________________________________________________________________________
The ways other people can help me are:
________________________________________________________________________
________________________________________________________________________
I will know that my plan is working if:
________________________________________________________________________
________________________________________________________________________
Some things that could interfere with my plan are:
________________________________________________________________________
________________________________________________________________________
31

General Coping Strategies
Things I can do Thoughts that can help Coping with feelings
Visit an Elder or Knowledge
Keeper and offer to be a helper
Attend a sweat lodge ceremony
Smudge
Have a cedar bath
Drink a cup of cedar tea
Go in the bush
Sit by the water
Make a tobacco offering in
gratitude for the day
Avoid people or places that
trigger problematic coping
strategies (i.e. tobacco use,
drinking, drug use, self-harm)
Identify and avoid high-risk
situations.
Take a “buddy” when going to a
risky place /situation.
Leave risky situations, or limit
how long you stay.
Phone someone for support
Go for a walk.
Read a book.
Exercise or do something
physical.
Stand tall and feel your body’s
strength. Remind yourself that
you are a strong person.
Hold onto something to ground
yourself (chair you are sitting in,
key ring, picture etc.)
Clean or do housework.
Offer a daily prayer of gratitude
Talk to an Elder or Knowledge
Keeper about the Seven
Grandfather teachings
Think kind thoughts about yourself
Remember the positive things
about using healthy coping
strategies.
Remember the negative
consequences of using
problematic coping strategies.
Tell yourself that feelings, even
difficult feelings, are normal.
Distract yourself by thinking about
something else.
Recognize when you are making
self-defeating statements or
rationalizations (i.e., I am such a
loser).
Plan ahead for any risky situations
or “loopholes” to your plan.
Imagine a stop sign when you are
having intrusive thoughts or
imagery.
Think about your future goals and
how to achieve them.
Remind yourself that you only
have to worry about what you have
control over today.
Remind yourself that you are in the
present and the past cannot hurt
you now.
Make a commitment to yourself
and remind yourself of it.
Think that you are in charge of
whatever decisions you make
about your safety.
☯ Talk to an Elder or
Traditional Healer
☯ Acknowledge your
internalized oppression
☯ Read inspiring literature on
self-growth or recovery.
☯ Ask yourself what you are
feeling (go through a
checklist of your common
“feeling triggers” –am I
lonely, sad, anxious,
scared).
☯ Give yourself permission to
feel emotions (don’t judge
your feelings).
☯ Express your feelings (cry,
smile, etc.,).
☯ Ask for support.
☯ Talk to someone about your
feelings.
☯ Find a creative outlet for
feelings (music, drawing,
painting, poetry etc.,).
☯ Get a journal and write to
yourself.
☯ Take time to soothe /
nurture yourself.
☯ Praise yourself for the
progress you have made.
☯ Use affirmations.
☯ Light candles to help you to
focus on your thoughts and
feelings.
☯ Write a letter to someone
about how you are feeling (it
32

Do volunteer work
Try meditation, deep breathing,
and relaxation tapes.
Try new hobbies or leisure
activities.
Practice saying no with both
your voice and body language.
Stay in contact with supportive
people.
Take care of yourself if you are
hungry, thirsty or tired.
Keep a visual reminder of the
negative consequences of your
problematic coping strategies
(i.e. court papers, photos)
Keep visual reminders or
written lists of the positive
consequences of the changes
you’ve made.
Reward yourself for your
efforts.
Go to a support group.
Listen to music. Sing. Dance.
Cook and eat nutritious food.
Practice being kind to yourself
Tell yourself that you are doing
well so far and don’t want to
interfere with the progress.
When feeling overwhelmed, make
a pro / con list and limit your
decisions until you feel less
overwhelmed.
Monitor your use and urges to use
problematic coping strategies
Think about the times in your life
(even if few) where you have felt
good about yourself. Try to get in
touch with the feelings of strength
and success that went along with
those events.
When a negative belief about
yourself pops into your head, try to
remember where it really came
from—who originally planted those
beliefs Think about challenging
them with other information that
you know about yourself, which
proves the beliefs to be false.
Be aware of any tendency you
have to make general statements
about yourself. Being human
means having good and bad days.
Post a copy of the Seven
Grandfather teachings where you
can review it each day
is better to not send the
letter, keep it, burn it, bury it,
flush it).
☯ Get a punching bag, or hit a
pillow or bed, scream into a
pillow.
☯ Throw rocks in the lake
☯ Talk to a pet / spend time
with animals.
☯ Go to a spiritual place
(anyplace you define as
spiritual).
☯ Create a safe or sacred
place in your home.
☯ Be kind to yourself.
☯ If you are afraid of being
overwhelmed by your
emotions, imagine them
coming through a tap where
you are able to control the
flow
33

Healing from commercial tobacco use: some traditional approaches
The following are ideas and suggestions and may not necessarily apply to all Nations. We recognize there are no
universal or pan‐Aboriginal approaches to healing commercial tobacco use.
A community member should always begin their traditional healing path by consulting with people s/he trusts to get
referrals to respected and recognized Traditional Healers, Elders and Medicine People within his/her community or
organization. An Elder in the community would be willing to help the community member who wants to quit by being
available throughout the process of their journey toward becoming a non‐smoker. When you seek the help and advice
of an Elder, Healer or Medicine Person, and give your offering of tobacco, they know that a request may be made as
tobacco is so sacred.
Tobacco is the first plant that the Creator gave to the peoples of Turtle Island. It is used as an offering for everything in
every ceremony. “Always through tobacco,” the saying goes. Traditional tobacco was given to us so that we can
communicate with the spirit world. It opens up the door to allow that communication to take place. When we make an
offering of tobacco, we communicate our thoughts and feelings through the tobacco as we pray for ourselves, our
family, relatives and others.
Tobacco has a special relationship to other plants: it is said to be the main activator of all the plant spirits. It is like the
key to the ignition of a car. When you use it, all things begin to happen. Tobacco is always offered before picking
medicines. When you offer tobacco to a plant and explain why you are there, that plant will let all the plants in the area
know why you are coming to pick them.
We express our gratitude for the help the spirits give us through our offering of tobacco. It is put down as an offering of
thanks to the First Family, the natural world after a fast. Traditional people make an offering of tobacco each day when
the sun comes up.
Traditional tobacco is still grown in some communities. For example, the Haudenosaunee people use a traditional
tobacco that they grow themselves and that is very sacred to them. Tobacco along with sage, cedar and sweetgrass
make up the Four Sacred Medicines.
In addition to speaking to a traditional person and making offerings, a community member can also find healing through
ceremony such as:
- daily smudges with the sacred medicines and prayers
- going on a fast
- going to a sweat
Many options are available for reconnecting with traditional activities, replacing unhealthy environments and activities
with healing ones, or distracting ones hands from the habit of cigarette smoking, such as:
- spending time in the bush
- traditional, jingle, fancy shawl, grass, chicken, etc. dancing
- beadwork and craft‐making
- hunting, trapping, cooking traditional foods
- singing
- drumming
(In part adapted from “The Four Sacred Medicines”. Anishnawbe Health Toronto, 2000, and through consultation with
the Enaahtig Healing Lodge and Learning Centre.)
34

5
Optimize Your Plan
In Session 4, the person was asked to identify some major triggers for commercial
tobacco use, and to think about ways to cope. In this session, the person will examine
what is working well and what needs further change to “optimize” the plan of action.
This session and the last session (Session 6) are devoted to “fine-tuning” and testing
out various coping strategies and supports.
A
sking for feedback from others is the primary focus of the fifth treatment session. Who are the
most helpful supports to changing commercial tobacco use These can include Elders, family
members, friends, colleagues or health professionals. The person is encouraged to ask for
feedback on his or her plan of action, identify what is missing or what he or she could try to do
differently, and to watch for saboteurs (people who are not supportive of change).
During this session, the helper could coach the person on ways to ask for specific feedback. This might
include identifying a number of possible options for each trigger or risk situation, and asking for specific
feedback on what might work best. The concept of “options” can be difficult to communicate to people.
Here is a suggested way of framing this task:
“In the past, commercial tobacco has been a way to cope with the trigger situations we talked about
last week. But, if you think about it, people who don’t smoke also experience similar triggers… they
just cope (or behave) in different ways. This week, we’re going to look at some of the other things
you could do when you’re confronted with one of these triggers. The more options you come up
with the better.”
Providing some concrete examples can be helpful in clarifying the task. Some possibilities include:
Trigger:
Options:
o Smoking while drinking coffee in the morning
o Switching to tea or juice
o Drinking coffee in a place that doesn’t allow smoking (like a coffee shop)

o Changing my morning routine
o Quitting coffee completely
o Continuing to have my morning coffee at home, but not smoking
After the person has generated three or more options, they are asked to reflect on the likely consequences
of each option – both short- and long-term, and positive and negative. Returning to the example above,
here are some of the possible consequences for each of the options listed:
Possible consequences to each option:
1. Switching to tea or juice
• Hard to give up my morning coffee
• I would feel tired
• It wouldn’t be the same
• I would be tempted to make a coffee
• I wouldn’t be as likely to crave a cigarette
• Tea or juice is healthier.
2. Drinking coffee in a place that doesn’t allow smoking (like a coffee shop)
• I might not have time to stop at a coffee shop in the morning
• More expensive
• Would be relaxing and a change of pace
• Gets me out of the house
• Not as tempted to smoke, since it wouldn’t be an option
3. Changing my morning routine
• I’ve been trying to do this already
• Helps with the cravings in the morning
• Doesn’t take me any more time, and might save me time
• Healthier
36

4. Quitting coffee completely
• Headaches
• I love the taste of coffee
• Not sure if I want to give it up – would feel even more deprived
• Healthier if I gave it up
5. Continuing to have my morning coffee at home, but not smoking
• Would be hard to resist smoking
• Wouldn’t have to make any more changes
Examining the costs and benefits of each option helps people to complete the next part of the exercise:
deciding on their best, and their second-best options. After looking at the pros and cons of each of the
options in our example, the person decided that Option #3 was the best, and Option #2 was the second
best.
The final part of this exercise involves coming up with an Action Plan for her best option, and another
plan for her second-best option. Here is a sample Action Plan for the option, “Changing my morning
routine”:
‣ Wake up 30 minutes earlier
‣ Do some type of exercise either at home or at the Community Centre
‣ Get out of the house first thing in the morning (got to work, go for walk, visit non-smoking
family or friends)
‣ Don’t linger at home with my coffee like I usually do.
People often have some difficulty making their Action Plans concrete. It is important to look at each step
in his or her plan, and ask the person: “Is this something you could do tomorrow” The key is to help the
person come up with the specific steps they will take for each of their best options.
“Homework” for the coming week involves trying out these options to see what works, and approaching
others to ask for feedback and “troubleshooting.”
Note that there are no specific “Clinical Tools” in this section – refer back to the plans and
handouts discussed in the previous sessions and help the person reflect on what is working well and what
further changes he or she can make.
37

6
Prevent Relapse
This final session is an opportunity to review the feedback from
personal supports received during the previous week, determine
strategies that are effective, and come up with alternative strategies
and plans as needed. Clients are invited, during this session, to
review what they have accomplished in counselling, and to reflect on
their successes and accomplishments. This session also explores with
people “what else is needed” with respect to continuing counselling,
supports or other needs.
W
hat has been helpful What more is needed These are the key questions
that guide this final counselling session. Ask the person to review the
feedback he or she received from his or her support network, with a goal
of identifying the steps and strategies that have worked well, along with
those that need some additional “fine-tuning.” The goal throughout these sessions has
been for the person to become his or her own teacher, through communicating a
general problem-solving approach that can be applied to a variety of behaviour change
goals. Ideally, at this point in counselling, the person has mastered the strategies of
identifying risk situations, generating options, and developing concrete Action Plans.
The person is also invited to review the Decisional Balance exercise that they
completed at the beginning of the counselling journey (Session 2). This is important,
since the Decisional Balance focused on hypothetical costs and benefits of change. It is
often the case that the actual costs are not as significant as originally anticipated. The
benefits to change may be greater than a person thought, or there may be other,
unanticipated benefits.
Finally, this session is an opportunity to identify and reflect on possible next steps.
These might include attending an ongoing support group, attending a self-help group,
reading self-help materials, or connecting with Elders or community supports or
programs or other ways of healing. The notion of change and recovery as an ongoing
process is useful. “Bumps in the path” are to be expected – the issue is how the person
addresses these temporary setbacks. A person can also be provided with additional
self-monitoring forms, and encouraged to continue to track triggers, possible
commercial tobacco use and coping strategies.

Session 6: Preventing Relapse
Clinical Tools
Decisional Balance exercise revisited
“If I were to relapse…” exercise
“I Can Quit” planning sheet
“Current Motivation and Next Steps”

Decisional Balance Sheet
Write down the good things (benefits) of quitting commercial tobacco use, as well as the less good
things (costs) of quitting. Then compare your answers with the ones that you wrote in Session 2.
Were there any differences For example, were there any benefits that you have experienced that
you had not anticipated Have the costs of quitting been as hard as what you thought at the
beginning of counselling
Continue Smoking
Benefits of: o Reward
o Helps getting started in the
morning (routine)
o Helps me deal with stress
Quit Smoking
o Feel better about myself
o Set a good example for children and
community
o Save money
Costs of:
o Smells bad
o Costs too much
o Skin damage
o Out of breath when I walk
o It will be hard to quit
o I will miss smoking
o Other people might not support me
wanting to quit
40

I CAN QUIT PLANNING SHEET
Prevent Relapse
Optimize
Strategize
Take Action
41

If I were to relapse….
…it would most likely be in the following situation:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
What coping strategies could I use to avoid this
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
This worksheet demostrates forward thinking. How would you feel if you
relapsed
This is another tool that can help prepare you to avoid relapse as it helps
you anticipate high risk situations and plan alternate strategies
42

Current Motivation and Next Steps
1. Where were you when you started this process, and where are you now
2. What do you need to do to continue to make positive changes
3. What is your next step
Completing this worksheet allows you to gain perspective on quitting commercial
tobacco use. Reflect on how this entire journey has gone from starting to think
about behaviour change, to continuing these efforts, and write down the next
step that you need to take moving forward. This gives you the chance to feel
proud about the progress you have made to date, gain confidence, and realize
that even if you have not yet met your ultimate goal – you are still farther ahead
than when you first started!
Additional resources that can support me…
Keep this list handy. It can have names, contact information, websites, favourite
quotes etc – whatever is meaningful to you.
43

Resources and Further Reading
Key Resources for Continuing Professional
Development in Motivational Interviewing
Online Training & Resources
Centre for Addiction and Mental Health
online courses, including MI:
http://www.camh.net/education/Online_co
urses_webinars/index.html
Clinical Training Institute: Online MI
courses including MITI coding and
Certificate Programs:
http://www.motivationalinterviewing.info/
Motivational Interviewing Home Page –
International Introductory and Advanced
Training Information:
http://motivationalinterview.org/training/in
dex.html
Books
Naar-King, S. and Suarez, M.
(2011). Motivational
Interviewing with Adolescents
and Young Adults. New York:
Guilford.
Rollnick, S., Miller, W.R. and
Butler, C.C. (2008).
Motivational Interviewing in
Health Care. New York:
Guilford.
Rosengren, D.B. (2009).
Building Motivational
Interviewing Skills: A
Practitioner Workbook. New
York: Guilford.
More resources are available at:
www.teachproject.ca
http://www.cancercare.on.ca/cms/one.aspxpageId=9322
44