Counsellors' Manual for Commercial Tobacco Cessation Treatment

Counsellors' Manual for Commercial Tobacco Cessation Treatment

Counsellors' Manual for Commercial Tobacco Cessation Treatment


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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.


© Centre for Addiction and Mental Health


This resource may be freely reproduced, adapted and used by any helper or community in accordance with OCAP principles

(Ownership, Control, Access and Possession).



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.


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


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


The simple formula for calculating pack years is as follows:

# of cigarettes / day X # of years smoked




___ 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.


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









3. Which cigarette would you hate most to give up The first one in the morning

All others



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



31 or more














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


How does commercial tobacco affect you and

others in your life



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






Number of





Test for





# of cigarettes / day X # of years smoked




___ pack years


Readiness to



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 ______________________________________________________



Exposure to 2nd hand smoke on a regular basis______________

OTHER COMMENTS ON ENVIROMENT (where you smoke, who you smoke with, etc)










(Include information on finances, employment, relationships/ support system, family, legal issues, current



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).


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


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


External Self Image Health

Opinion of others

Personal Appearance

Images of Illness


Financial Reasons


Environmental Factors








Health deterioration


Health Improvement




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.


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


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


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.


Session 2: Dealing with ambivalence

Clinical Tools

o Reasons for Change form

o Decisional Balance form

o Readiness Ruler


Traditional Alternative to Readiness Ruler: TOBACCO CESSATION MEDICINE WHEEL - AN ANISHNAWBEK


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. _______________________________________________________________




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


o Helps me deal with stress

Quit Smoking

o Feel better about myself

o Set a good example for children and


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


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








eg: poor judgment/decision making, difficulty

concentrating, bipolar illnesses, depression, etc.

How confident are you that you could make this change




10 How has your tobacco use impacted you

How has quitting in the past affected you


eg: confusion, loss of

connectedness, and/or

problems in the physical,

emotional or mental aspects.


How ready are you to make this




eg: low self-esteem, loss of ability to

cope, relationship difficulties, etc.

How important is it to change this behaviour


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



Daily Diary



(How many



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)










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).


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.


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.


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).


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


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


Document prepared by CAMH Nicotine Dependence Clinic – adapted from:



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


‣ Headache – One in four smokers reports a mild headache at some point during their quitting


‣ 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


‣ 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.


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.


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.


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


6. Pregnant women should never use nicotine replacement


7. People under age 18 should never use nicotine replacement


8. Stop-smoking medications should not be used in combination with


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


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


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).


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


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



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.


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


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.


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


Triggers and Coping Skills

Sample Plan


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


Coping Skills


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:




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


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


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


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


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


Plan ahead for any risky situations

or “loopholes” to your plan.

Imagine a stop sign when you are

having intrusive thoughts or


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,


☯ 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


☯ Find a creative outlet for

feelings (music, drawing,

painting, poetry etc.,).

☯ Get a journal and write to


☯ 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


☯ Write a letter to someone

about how you are feeling (it


Do volunteer work

Try meditation, deep breathing,

and relaxation tapes.

Try new hobbies or leisure


Practice saying no with both

your voice and body language.

Stay in contact with supportive


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


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


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


☯ Throw rocks in the lake

☯ Talk to a pet / spend time

with animals.

☯ Go to a spiritual place

(anyplace you define as


☯ 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



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.)



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.


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:



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


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


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


‣ 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.



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.


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


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



Prevent Relapse



Take Action


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


This is another tool that can help prepare you to avoid relapse as it helps

you anticipate high risk situations and plan alternate strategies


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.


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:



Clinical Training Institute: Online MI

courses including MITI coding and

Certificate Programs:


Motivational Interviewing Home Page –

International Introductory and Advanced

Training Information:




Naar-King, S. and Suarez, M.

(2011). Motivational

Interviewing with Adolescents

and Young Adults. New York:


Rollnick, S., Miller, W.R. and

Butler, C.C. (2008).

Motivational Interviewing in

Health Care. New York:


Rosengren, D.B. (2009).

Building Motivational

Interviewing Skills: A

Practitioner Workbook. New

York: Guilford.

More resources are available at:




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