Tobacco Treatment Specialist (TTS) Training
I. Determinants of Nicotine Dependence: Biological, Psychological and Social Factors
Until relatively recently, nicotine dependence was not recognized as a legitimate disorder, in part because its manifestations do not appear to be as severe and as potentially disruptive to everyday functioning as dependence on other drugs. However, closer study has revealed that nicotine dependence shares many features with other drug dependence, notably similar biological actions on brain reward and withdrawal circuitry, compulsive use, tolerance, etc. Moreover, because tobacco, the primary source of nicotine, is legal, availability is not a barrier. Nicotine dependence has an insidious onset, and once entrenched, takes addictive hold of the tobacco user, such that repeated efforts to quit are often met with failure, resulting in a lifetime of tobacco addiction.
This module will provide the knowledge base for understanding the biological, psychological and social basis of nicotine dependence. This will include learning about the basic brain processes that determine drug dependence in general and the development and maintenance of nicotine dependence in particular. We will look at how nicotine is absorbed, distributed and eliminated and review the diagnostic criteria for nicotine dependence and withdrawal.
Goal of the module:
Provide tobacco treatment specialists with knowledge of the biological, psychological and social as determinants of nicotine addiction so they can better understand and treat tobacco users.
1. Describe the prevalence and etiology of nicotine dependence.
2. Define the BioPsychoSocial Model.
3. Discuss Social factors related to nicotine dependence and cessation.
4. Discuss Psychological factors related to nicotine dependence and cessation.
5. Discuss Biological factors related to nicotine dependence and cessation.
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II. Guidelines for Systems and Professionals
Effective tobacco dependence treatment requires integration of agency policies and protocols with the skill of individual providers. The role of a tobacco treatment specialist may vary depending upon the setting and other professional training of the individual clinician. This module will address systems level issues, including elements of program protocol, evaluation, and potential barriers and facilitators.
Professional responsibilities will be discussed including ethical standards, the role of clinical supervision and self-care issues for the treating professional, setting boundaries and termination of treatment. Opportunities for professional development such as the UMass Tobacco Treatment Specialist Certification Program will be described.
Goal of the module:
The goal of this module is to help the tobacco treatment specialist understand their role within a system and provide information regarding the basic elements of program management.
1. List the Public Health Service recommendations for optimal structure and intensity of effective tobacco treatment intervention.
2. Describe the range of established and innovative treatment modalities.
3. List program components including clinical protocols, evaluation recommendations and billing options.
4. Discuss potential barriers and opportunities to implementing tobacco treatment in healthcare systems.
5. Define the role of the TTS: Professional development and responsibilities.
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III. Introduction to Motivational Interviewing
This module endeavors to teach principles of effective counseling for health-risk reduction by lifestyle change. In particular, participants will learn how to engage and assist individuals seeking to modify their use of tobacco and nicotine. These lessons are presented within the larger context of our current knowledge regarding a number of related topics including: Natural recovery and the stages of change, motivation, resistance, and behavioral self-control. The penultimate goal is to teach health care professionals how to have constructive conversations with individuals regarding the whys, whens, and hows of smoking cessation and the reduction in nicotine use.
There is perhaps nothing more frustrating to the conscientious and committed health care professional than the failure of individuals to heed sound healthcare advice regarding the modification of their nicotine use. Well known is the fact that most clients do not comply with even the simplest and most straightforward health care directive. Health care providers advise, lecture, confront, exhort, and even try to shame smokers into compliance; all to little avail. It’s as if with every provider expression of concern, the client digs further into the crater of resistance and noncompliance. What is left to do?
Motivational Interviewing (Miller & Rollnick, 1991, 2002) is a style of talking with patients about health-risk reduction and behavior change that integrates the principles of patient-centered medicine, client-centered psychotherapy, and social learning theory. Based upon the tenet that most individuals already have the requisite skills to successfully modify lifestyle and decrease health-risk, MI employs strategies that will enhance the patient’s own motivation for and commitment to change. Motivational Interviewing integrates an empathic, non-confrontational style of interviewing with powerful behavioral strategies for helping clients convince themselves that they ought to change. Consequently, resistance is minimized, self-motivation maximized, and treatment compliance and behavior change secured.
Motivational Interviewing provides an effective alternative to coercion, confrontation, and exhortation as a means of promoting behavior change and treatment compliance in the nicotine-dependent individual. The principles and strategies of Motivational Interviewing provide the backbone for this course, organizing a broad knowledge base and skill set pertaining to counseling the individual with nicotine dependence.
Goal of the module:
To provide tobacco treatment specialists with the requisite knowledge and skills to effectively implement motivationally-oriented counseling strategies that promote readiness to change and subsequent abstinence in individuals who are nicotine-dependent.
1. Participants will apply patient-centered principles of health-risk reduction to the problem of effectively counseling individuals with nicotine dependence.
2. Participants will describe the basic principles of motivational interviewing and stage-informed counseling requisite to the effective treatment of nicotine dependence.
3. Participants will describe the limitations of the direct persuasion or confrontational interviewing style.
4. Participants will demonstrate how to effectively implement the initial phase of nicotine dependence counseling utilizing reflective listening skills.
5. Participants will describe the five categories of change talk.
6. Participants will demonstrate skills necessary for negotiating a behavioral change plan regarding nicotine use.
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IV. Pharmacotherapy for the Treatment of Nicotine Dependence
The Public Health Service guideline recommends that all tobacco users trying to quit be offered pharmacotherapy. There are currently seven first-line medications approved by the FDA for use in smoking cessation: five nicotine replacement products; bupropion, an anti-depressant; and varenicline, a partial nicotine agonist. While the effectiveness of each product has been demonstrated there are multiple factors to be considered when choosing the appropriate pharmacotherapy for each individual.
The principles of evidence-based medicine will be reviewed and applied to the pharmacologic treatment of tobacco dependence. This course will provide an overview of factors specific to each medication (agent factors), individual client considerations and medical issues to be addressed when recommending a course of therapy.
The anticipated effects of the seven first-line tobacco treatment medications for patients with the following conditions will be discussed: Cardiovascular Disease (CVD), Chronic Obstructive Pulmonary Disease (COPD), Diabetes Mellitus (DM), Substance Use Disorders, and select Mental Illnesses. The use of these medications for special populations including pregnant and lactating women, and adolescents also will be reviewed.
Goals of the module:
1. Provide tobacco treatment specialists with the knowledge required to apply the principles of evidence-based practice in the use of pharmacotherapy to treat tobacco dependence.
2. Provide sufficient background information regarding considerations when recommending pharmacotherapy for clients with CVD, COPD, DM, Substance Use Disorders, and select Mental Illnesses, clients who are pregnant or nursing, and adolescents.
1. Review current pharmacological approaches to treatment of nicotine dependence.
2. Describe and apply evidence-based medicine principles to pharmacological treatment for nicotine dependence.
3. Understand the anticipated effects of the different forms of pharmacologic treatment in select medical conditions.
4. List additional special concerns and issues that affect the choice of pharmacologic treatment.
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V. Cognitive and Behavioral Treatment Strategies
This module will provide basic knowledge about the process of quitting smoking and will present tobacco treatment from within a social learning perspective. Treatment will be presented on a continuum of intensity of clinical contact, from self-help (no contact) to minimal contact/brief advice to brief counseling to intensive counseling. Tobacco treatment strategies will be presented within a framework that includes pre-cessation, cessation and relapse prevention phases. Lifestyle changes that support quitting smoking and a generally healthy lifestyle will be discussed. The empirical basis for treatment strategies discussed will also be provided. This module will provide the requisite knowledge and skills to allow tobacco treatment specialists to assist tobacco users to quit and remain abstinent, and will include an emphasis on tailoring treatments to smokers’ readiness for change, level of nicotine dependence, psychiatric co-morbidity, and cultural considerations.
Goals of the module:
1. To provide tobacco treatment specialists with knowledge of and the empirical basis for tobacco treatment strategies, ranging from minimal contact to intensive intervention.
2. To provide tobacco treatment specialists with the necessary skills to assist smokers through the pre-cessation, cessation and relapse prevention phases of quitting smoking.
1. Discuss treatment considerations for priority populations.
2. Describe the specific and appropriate strategies for the pre-cessation phase of treatment, including how to tailor the strategies to the unique needs of the individual smoker.
3. Describe the specific and appropriate strategies for the cessation phase of treatment, including how to tailor the strategies to the unique needs of the individual smoker.
4. Describe the specific and appropriate strategies for the relapse prevention, including how to tailor the strategies to the unique needs of the individual smoker.
5. Discuss harm reduction as a treatment strategy.
6. Describe the advantages and characteristics of group interventions for tobacco treatment.
7. Discuss appropriate strategies for managing group interventions.
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VI. Intake, Assessment and Treatment Planning
To understand and treat your clients who use tobacco, a comprehensive evaluation of their smoking history and smoking behavior is essential. This is a multi-level process that begins with the first encounter with the client and continues throughout the treatment program. This session will address how to initiate this process in order to establish a foundation for an effective working relationship. It will review the questioning skills needed to assess key factors of the client’s smoking and quitting history, level of addiction, medical, psychological, environmental, and social factors which may support or inhibit quitting smoking. This session will also provide the learner with materials and the skills needed to work with the client to customize a treatment plan based on the comprehensive assessment. In addition, it will address the importance of ongoing assessment and evaluation of the client’s response to the interventions, the aftercare plan, and referrals to other resources to offer reinforcement to help the client maintain a smoke-free lifestyle.
Goal of the module:
To apply knowledge of counseling theory and practice, nicotine dependence, and other psychosocial factors to assess clients who use tobacco to determine effective strategies for quitting tobacco use and to tailor the intervention to help clients achieve long-term abstinence.
1. Describe the key components of a comprehensive intake process including; demographics, tobacco use, quitting, and medical/psychiatric history, dependence, social, cultural, environmental factors.
2. Demonstrate how to use a carbon monoxide monitor.
3. Identify strengths and potential barriers to treatment.
4. Conduct interviews in a manner which advances stage of change and promotes self-efficacy.
5. Review the information gathered during an initial assessment in order to develop an appropriate treatment plan.
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