Inspired by Nova Scotia's comprehensive Tobacco Control Strategy and in an effort to support Capital Health's 100% smoke-free policy, the Addiction Prevention and Treatment Services (APTS) branch of Capital District Health Authority researched, designed and implemented an innovative tobacco intervention program. The success of the Capital approach, combining peer support, adult education concepts, addictions treatment knowledge, and free pharmacological aids, has sparked interest and dialogue among Canadian and American addictions professionals. The following article describes the rationale, guiding principles, key components and future directions of APTS's "To Be Tobacco Free" program.  

Rationale

By early spring 2003, through a phased-in approach, Capital District Health Authority implemented its 100% smoke-free policy, prohibiting smoking on all Capital Health sites. In an effort to support those most affected by this policy, Addiction Prevention and Treatment Services (APTS) designed and delivered a tobacco intervention program to employees, physicians and volunteers. Programming was based in best practice and was accessible within all Capital Health sites. The results of this early pilot were evidence that the Capital approach - one that combined peer support, adult education concepts, addictions treatment knowledge and free pharmacological aids - created a positive treatment environment conducive to learning and the achievement of long-term abstinence.  

Around this time, the comprehensive provincial Tobacco Control Strategy, endorsed by the government of Nova Scotia in 2001, was in the early stages of implementation. Treatment and cessation was a key component of the strategy, and the provincial Department of Health and Office of Health Promotion challenged Addiction Services agencies at the district level to create cost-effective, clinically significant and accessible tobacco intervention programs. This provided the impetus (including the provision of budgetary and staff support) for Capital Health to expand on the initial APTS pilot program. In the fall of 2003, following both therapeutic and educational refinements based on feedback from participants and suggestions from front-line facilitators, the "To Be Tobacco Free" program was unveiled to the public.

"To Be Tobacco Free"

Today, the "To Be Tobacco Free" program continues to enhance health and reduce harms associated with the use of tobacco products and is available to the Capital Health District's 395,000 residents (40% of Nova Scotia's population). Facilitators with specific training in the field of addictions deliver 300 minutes of core content comprised of a "Getting Started" orientation session and a four-step "Keeping It Going" group program. The curriculum, guided by cognitive-behavioural research, is action-oriented, adaptable and delivered in a motivational style. It offers participants a valuable opportunity to increase self-efficacy skills and plan for success in a learning environment free from social stigma, moral messaging and fear.  

Fear arousal techniques ("black lung" images, for example) or messages that equate tobacco use with a "character flaw" tend to create resistance within participants and can lead to greater dropout rates. In contrast, the Capital approach presents nicotine addiction and tobacco use solely within a health context. Drawing upon motivational interviewing (Miller and Rollnick 1991) techniques, facilitators meet clients "where they are" in their stage of change and assist with their positive progression. Participants set personal goals around the reduction and elimination of tobacco in their lives and are empowered to replace extrinsic motivators for change with intrinsic ones during the course of treatment.  

The success and popularity of "To Be Tobacco Free" is evident. APTS provided treatment options to over 1,900 tobacco users in 2004-05. Outcome monitoring indicates a 33.2% cessation rate six months post-intervention, with an additional 44% of participants using less tobacco and still trying to stop.  

Guiding Principles

"To Be Tobacco Free" utilizes a combination of nicotine treatment standards and best practices that have been shown to produce the highest abstinence rates (see Fiore et al. 2000 for a comprehensive review). The program operates within a harm-reduction model acknowledging the continued substance use of individuals, but seeking to minimize the harm that such behaviour can cause. Nicotine replacement therapy (NRT) is available at no cost to participants and positioned as a "craving control" medication that assists with the biophysiological symptoms of nicotine withdrawal. Early on in the process, facilitators frame tobacco use as an addiction or chronic disease characterized by a lack of control over the substance. This foundation enables the exploration of various components of recovery manifesting along a biological, psychological, social and spiritual spectrum (Hajela 2000). Biological or physical factors (and the use of NRT), then, are but one aspect of the recovery process, and participants who understand, embrace and actively address the multiple aspects of the addiction have a much smoother, safer and successful journey to tobacco freedom.  

Inspiring Change and Building Motivation

Not every tobacco user is ready to change their behaviour, and studies have identified a consistent behaviour change pattern that can be helpful in understanding and facilitating change. The transtheoretical model (Prochaska et al. 1992) is a framework common within addiction settings emphasizing stages of change: precontemplation, contemplation, preparation, action and maintenance. Applied to tobacco use, precontemplators are not thinking about stopping; contemplators are thinking about stopping in the next six months, while those in preparation are planning to stop within a month, and those in the action or maintenance stage have significantly reduced or stopped tobacco use. Health professionals who use this model assess an individual's readiness to change and deliver specific interventions tailored to the appropriate stage in order to increase the likelihood of success.  

APTS staff designed the "Getting Started" information session with the precontemplative individual ("dragged" there by a loved one) or the contemplative individual (curious but not willing to commit) in mind.   Participants attend a one-hour supportive presentation in their community designed to motivate behaviour change through humour, unconditional support and the evidentiary truths about cigarettes. Participants receive a self-test of nicotine addiction, a workbook, a menu of upcoming support groups and the opportunity to use a carbon monoxide monitor. Outcome monitoring indicates over 84% of individuals who attend a "Getting Started" session continue the process by registering for and attending a "Keeping It Going" support group. When individuals take this seemingly simple action, they demonstrate what is, in actuality, a significant step into the preparation or action stage of change and, as a result, facilitators meet with less resistance as they encourage individual change within a group dynamic.  

Motivational interviewing (Miller and Rollnick 1991) techniques are utilized to achieve progression and movement along the continuum of change. This directive, client-centred counselling style elicits behaviour change by helping clients explore and resolve ambivalence. Compared with nondirective counselling, or a parental "you must stop smoking now" approach, motivational interviewing (MI) enables facilitators to focus clients and direct them toward their goal. "To Be Tobacco Free" facilitators incorporate the requisite skills of MI and build motivation within clients by

• expressing empathy and affirming feelings
• rolling with resistance and avoiding argumentation  
• supporting self-efficacy and boosting self-confidence
• encouraging clearly defined reasons for stopping
• creating dissonance between reasons for using and benefits of stopping
• acknowledging that resistance indicates disparity between the intervention and the participant's readiness to stop

 

Facilitating Learning

At times in healthcare settings, consumers will look to a facilitator to fill the role of "expert." This expectation is often a result of many contacts with healthcare providers who "tell" clients what to do - a "do as I say so you will get better" approach. Forcing information onto a client rather than working with him or her often leads to disengagement, however. The Capital approach is to empower participants to become their own experts, taking ownership of their recovery because, after all, no one knows more about clients' tobacco use than clients themselves.

APTS tobacco intervention personnel help participants learn more about tobacco use while exploring and valuing feelings, beliefs and experiences. Facilitators engage, challenge and involve clients in dialogue rather than lecture them. This method of promoting learning through reflection and discovery is rooted within the field of adult education. Adult learners draw heavily on life experiences and previous learning attempts. The success and popularity of the "Keeping It Going" group program is in large part due to participants feeling comfortable, at ease and safe sharing their personal stories of struggle and success. Adapted from core adult education tenets, the Capital approach to achieving success in a group format is in understanding the difference between providing instruction and facilitating learning. Keys to making this distinction include

• a group leader who is a facilitator (with specific training in the field) rather than a subject matter expert
• encouraging two-way communication rather than a one-way "I talk, you listen" format
• ensuring that participants are asked instead of told
• inviting questions and promoting discussion instead of a "listen and take notes" approach  
• emphasizing knowledge application and building on (and learning from) previous experience rather than knowledge acquisition alone

 

Specific Program Components and Content

"Getting Started"

The "Getting Started" (GS) orientation introduces interested individuals within the Capital Health district to the "To Be Tobacco Free" cessation program through an interactive, non-judgmental information session. Registration is not required, and there is no fee attached to the service. APTS offers approximately five GS sessions monthly around the district. The 60-minute presentation touches upon the role and proper use of nicotine replacement therapy (NRT), tobacco dependence, basic cigarette science and the benefits of living tobacco free. The focus is on providing positive messages of support while introducing basic themes around stages of change and the addictive process so attendees can better assess their level of readiness and understand the process involved in becoming tobacco free. Those in attendance receive an informative workbook, an invitation to participate in outcome monitoring and a list of upcoming "Keeping It Going" (KIG) opportunities. NRT is not available at the GS.

Registration  

Anyone who has attended a GS session and answers "yes" to the "are you ready?" question may choose to register for the four-week KIG support program through one central point of contact. The "tobacco intervention line," which appears on all program literature and advertising material, offers callers information on upcoming programs, registration instructions and the opportunity to leave a detailed message. One central point of contact for all things pertaining to tobacco within APTS limits confusion for staff and reduces frustration for clients.  

"Keeping It Going"

Capital Health holds KIG sessions in a variety of health and community centres throughout the region. This closed group support opportunity for up to 15 participants is a four-week, cognitive-behavioural-based educational program. Trained facilitators present practical advice on coping, combined with effective thinking techniques and behaviour-modification skills to assist participants as they critically reflect on their tobacco use and the relationship they have with the substance. Through group sharing and personal reflection, participants examine prevalent thoughts and beliefs that may hinder success in cessation. Facilitators also accentuate the power of developing a behavioural-change strategy or "daily action plan" for living tobacco free.  

Program staff structure each one-hour KIG session around a theme. In the first week, participants explore the concept of decisional balance, identify personal "triggers" and begin to plan the process of stopping and living tobacco free. In week two, facilitators "normalize" common physical symptoms of withdrawal equating them to "signs of recovery," and discuss various coping strategies. Week three explores the complexities of "emotional withdrawal" and the power of "effective thinking." In week four, participants look at "return to use prevention," the meaning of "never stop stopping," the NRT "stepping down" process and other community-based support opportunities.

Some cognitive interventions utilized during a KIG include

• recognizing, discussing nicotine as an addiction
• discussing feelings, behaviours of addiction
• recognizing and addressing defensiveness
• discussing loss of control of use (cannot have "just one")
• introducing various options for support

Behavioural approaches to treatment might include

• setting a stop date
• planning for one craving (or "one day") at a time
• identifying and using support systems
• avoiding all high-risk situations
• connecting with other recovering users

Nicotine Replacement Therapy (NRT)

Participants may also receive up to eight weeks worth of Nicotine Replacement Therapy (NRT) to support their cessation efforts, which is provided free of charge in conjunction with programming. The recommended dose of NRT is linked to the client's score on the Fagerstrom Test of Nicotine Dependence (Heatherton et al. 1991) completed at the GS. If they so choose, those scoring six or above are encouraged to begin with a step one (21 mg) patch, while those scoring five or below start with step two (14 mg). Clients may take a one-week supply of NRT at each session they attend. Provided they attend all four sessions, they can receive an additional four-week supply at the final session (for a total of eight weeks of NRT).

Central office staff maintain an inventory of NRT, and facilitators sign out quantities appropriate to group size when needed. Providing NRT in a front-line fashion

• allows for proper budget management
• enables frequency of service to be based on available inventory
• prevents added costs at the retail (pharmacy) level
• allows APTS to negotiate pricing directly with manufacturer through the provincial drug distribution program
• allows for close monitoring of client use and controlled messaging regarding role of NRT within a complete cessation program

 

Outcome Monitoring

A key component to the success of a tobacco cessation program is whether participants have been able to remain tobacco free. To assist with outcomes measurement, an APTS staff person contacts consenting clients at three, six and twelve months post-intervention. Along with providing outcomes data, this contact provides accountability for the participant and increases the likelihood of long-term abstinence. The staff member asks clients about their current tobacco use, their use of NRT and satisfaction with programming via a brief telephone interview.  

Future Directions

The success of the Capital approach to tobacco treatment and cessation is evident. "To Be Tobacco Free" continues to support community members who are ready to address the harms associated with tobacco dependence whether they are just getting started in their efforts to live tobacco free or successfully keeping it going. As the Capital Health tobacco intervention team looks to the future, one goal is to reach out to less motivated and high-risk tobacco users - such as those found in mental health and addiction treatment settings - providing effective community interventions adapted from research-based initiatives. APTS recognizes that, as general public tobacco use rates continue to decline across the country, the burden of disease, financial hardship and death caused by tobacco dependence falls to these "special populations." The chronically mentally ill, for example, have very high using rates, face unique barriers to cessation within some treatment facilities and are particular targets of the tobacco industry (see Parle et al. 2005). One proposal to help reduce barriers between high-risk users and treatment is the concept of a "nicotine maintenance clinic" where those who are addicted to nicotine and are most vulnerable can have open access to clean, free nicotine (in the form of NRT) and receive counselling in a welcoming setting. This is a concept worthy of further exploration.  

By advocating for change, entering into collaborative research opportunities (including studies in personality predisposition such as anxiety with Dalhousie University faculty) and building partnerships with government, social service providers and community groups, Capital Health Addiction Prevention and Treatment Services is striving to become a centre of excellence in the treatment of tobacco dependence. It is a capital approach, and it is working.  

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