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1 Learning A bout Healthy Living TOBACCO AND YOU Written in 2004, Contributors: Jill Williams, MD Douglas Ziedonis, MD, MPH Nancy Speelman, CSW, CADC, CMS Betty Vreeland, MSN, APRN, NPC, BC Michelle R. Zechner, LSW Raquel Rahim, APRN Erin L. O’Hea, PhD Edited & Revised February 2012 RWJMS Division of Addiction Psychiatry Copyright© reserved. 2012 UMDNJ ‐ Robert Wood Johnson Medical School ‐ All rights

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3 This is a collaborative project between which is funded by the New Jersey Division of Mental Health Services The authors wish to thank Margaret Molnar, Special Assistant to Director of Consumer Affairs Alan G. Kaufman, Division Director, New Jers ey Division of Mental Health Services Robert Eilers, MD, Medical Director, New Jers ey Division of Mental Health Services for their support of this project. All rights reserved. No part of this document may be reproduced unless permission of the New Jersey Division of Mental Heal th Services is first obtained. First Printing September 2004 Revised December 2004 Revised June 2005 Revised March 2011 Revised February 2012

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5 Section 1 Introduction to Learning About Healthy Learning Living Manual About Section 2 General Structure of a Treatment Group Healthy Living Section 3 Tobacco Dependence TOBACCO AND YOU Treatment Medications Section 4 Group I Facilitator’s Guide Section 5 Group I Consumer’s Handouts Section 6 Group II Facilitator’s Guide Section 7 Consumer’s Handouts Appendix/Forms Section 8 Resources and Revised February 2012 References

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7 Preface 2012 Preface It has been seven years since the development of the Learning about Healthy Living: Tobacco and You (LAHL) Treatment Manual. In that time there have been numerous updates in the field of treating tobacco dependence including the FDA approval of the 2008 Update: Treating Tobacco Use Chantix (varenicline) and the publication of and Dependence Clinical Practice Guideline (available at http://www.surgeongeneral.gov/to bacco/treating_tobacco_use08.pdf ). A pilot implementation study of Learning about Healthy Living in New Jersey outpatient and partial hospital sites indicated good consumer attendance, and high levels of consumer interest and participation. Clinicians felt the program was easy to implement with limited training (Williams et al., 2009). LAHL was also implemented and evaluated by a group outside of NJ who had a similarly positive experience (Lee et al., 2011). When implemented in 9 psychoso cial rehabilitation clubhouses in North Carolina, the LAHL treatment was felt to be feasible and well-received by consumers and staff. Many other organizations from across the country are using it in their behavioral health red to inpatients in NJ state psychiatric settings. Since 2007, LAHL groups are offe hospitals and we are aware of least eight ot her states that are implementing LAHL in their behavioral health treatment settings. We are also starting to have consumer peer counselors conduct LAHL Group 1 in self-hel p centers in New Jersey with positive results. LAHL is listed as best practices in the NASMHPD 2007 Toolkit, Tobacco-Free Living in Psychiatric Settings: A Best Practices Toolkit Promoting Wellness and Recovery (http://www.nasmhpd.org/index.cfm ). creased awareness of the problem of tobacco In the last decade there has also been in use in the mentally ill and many influential and national groups have gotten involved. Much more, however, still needs to be done and even recent reports indicate a lack of access to tobacco treatment services in most mental health and addictions treatment settings (Peterson et al., 2003; Montoya et al., 2005; Friedman et al., 2008). The continued high prevalence of smoking among th ly related to several e mentally ill is like factors including the lack cessation services in the behavioral health setting. Additional barriers include that tobacco addiction is undervalued as a problem, that behavioral health professionals and systems have been slow to change, that professionals are unaware of evidence-based treatment fo r tobacco dependence, that reimbursement remains poor, and that there is a lack of hope and knowledge among consumers, family members, service providers and mental health advocates (Williams 2011b). In the last decade, we have developed a comprehensive model for Mental Health Tobacco Recovery in New Jersey (MHTR-NJ ) that has the overarching goal of improving tobacco cessation for smokers with serious mental illness (Williams et al., Learning about Healthy Living – Revised 2012 Page | 1

8 Preface 2012 2011a). Each of the components of the MHTR-NJ model contributes to the two core goals of this model: to increase demand for tobacco cessation services for mentally ill smokers and to help more smokers with mental illness to quit. Consistent with Center for Disease Control (CDC 2007) recommend ations for Best Practices for Tobacco Control, several interdependent elements ar e necessary to meet the goal of improving tobacco cessation in a population. In the MHTR-NJ model we emphasize efforts in the community (at the level of the consumer, fami ly member or advocate), in the clinical treatment setting (at the level of the provider or clinician) and in the environment (at the level of the agency or larger mental he alth system), although considerable overlap exists. A continuation between community and treatment setting is desirable as it creates a bridge to bring tobacco users into treatment and has implications for continued community support before and a fter treatment has been completed. The model also demonstrates the intersection between the environment, the treatment setting and the community in addressing tobacco. When these three elements come together we can expect the greatest success in increasing demand for tobacco services and helping more mentally ill smokers to qu it. The LAHL manual is one technique for increasing demand for tobacco treatment se rvices by working with low motivated smokers. dated references and sections on new This 2012 Version of LAHL includes up medications. We have also done edit s throughout to make the materials more appealing. We hope you find this updated version improved since the original edition. As always your feedback is welcomed ( [email protected] ). Learning about Healthy Living – Revised 2012 Page | 2

9 SECTION 1: Introduction 2012 Introduction to Learning about Healthy Living: Tobacco and You The aim of this treatment manual is to provide a format to address tobacco for smokers who are either prepared to qu with a serious mental illness it smoking or who are simply contemplating quitting in the future. This manual has been developed with input from mental health consumers and treatment sta ff. Their feedback has been incorporated into the sessions to make the treatment practical and easy to use. The manual takes a real-world approach at addressing tobacco a ddiction in the mental health setting and can be implemented by a broad range of mental health professionals and is on addressing tobacco, this manual paraprofessionals. Although the emphasis includes sections on other aspects of health y living including improving diet, increasing activity and managing stress. This treatment is designed for all types of smokers with different mental health problems. It assumes that not everyone using this treatment will be immediately ready to quit smoking, but has the overall goal of moving consumers towards a tobacco-free lifestyle. This treatment is designed as two groups. It is designed so that consumers can progress from Group I to Group II, when ap propriate or desired. Each topic is organized as a Chapter that can be discussed in a single group treatment session. Each at contain educational information as well Chapter includes handouts for consumers th as questions for discussion. The Facilitator’s Guide has a corresponding section for and suggested approaches for each topic. every Chapter that includes goals, objectives Section 8 (Appendix/Forms) includes additional supplementary materials and forms that are an optional resource for the Fa cilitator implementing the Learning about Healthy Living approach. The Chapters are designed to be used sequentially, as in a weekly group treatment, although each also stands alone as a unique topic related to tobacco use and healthy living, which can be integrated into other treatment approaches. Organization of the Manual This manual is divided into 8 sections. These include an introduction to the overall Learning about Healthy Living approach, de scription of the general structure of the treatment group, two group treatments wi th corresponding consumer handouts and facilitator guides, a chapter on tobacco dependence treatment medications and supplementary information including additional resources and useful forms. Group I “Learning about Healthy Living” Group I ‘Learning about Healthy Living” is an educational and motivational based intervention, which is useful for all smoker s with mental health problems. Group I has an open-ended format with rolling admission, and is not time limited. The overall goal of Group I is for consumers to gain knowle dge and insight to consider moving toward a tobacco-free lifestyle. Furthermore, by part icipating in Group I, consumers will learn about other issues related to healthy living su ch as nutrition, physical activity, and stress Learning about Healthy Living – Revised 2012 Page | 3

10 SECTION 1: Introduction 2012 management. This group will provide consume rs with detailed information regarding the risks associated with smoking, what is in cigarettes, the benefits of quitting smoking, ways to quit smoking, and general healthy li festyle behaviors that can assist them in quitting smoking. Consumers can continue coming to Group I as lo ng as they desire and will only advance to Group II when they have decided they are ready to take action to quit smoking. Group II “Quitting Smoking” ed treatment for smokers struggling with a Group II “Quitting Smoking” is an action-bas mental illness who are ready to try to quit smoking. Group II emphasizes techniques for quitting to improve success and reduce risk of relapse. Group II is a closed group format and lasts 8 to 10 weeks. There should be at least 4 individuals committed to quitting in rther, although most consumers will have order for this group to be carried out. Fu completed Group I as a pre-requisite, some consumers may come to treatment ready to quit and begin with Group II. In this way, th e treatment is flexible and can be modified to meet the needs of the smoker. This manual was designed for several reasons: the relationship between tobacco use and 1. To give the consumer information about mental illness 2. To give the consumer information about the recovery process from tobacco addiction, including educating them about the treatment. 3. To help the consumer to gain motivation about wanting to lead a tobacco-free lifestyle and quit smoking. 4. To help the consumer develop skills that will assist them to quit using tobacco and get healthy. 5. To teach the consumer struggling with a mental illness the specific relapse prevention issues that are most relevant to them. 6. To use the group format to structure the treatment sessions and also provide additional support and modeling experien ces for the consumer struggling with a mental illness. Preparing Participants for Group It is preferable that all smoking consumers should be seen for an assessment prior to being included in the group. A comprehensive self-report tobacco use assessment form is included in Section 8 (Appendix/Forms). It is anticipated that it might take a consumer 15-30 minutes to complete this assessment form that may be best done outside of the group time and with individual discussion with the group facilitator. Completion of this assessment may not always be possible prio r to beginning “Group I: Learning about Healthy Living”. In these inst ances, the facilitator may want to give the during the Introduction Group. This consumers a briefer assessment to complete assessment should include their current smoking level, past history of quit attempts and Learning about Healthy Living – Revised 2012 Page | 4

11 SECTION 1: Introduction 2012 nicotine withdrawal symptoms, and current thoughts about quitting. An additional assessment tool (On the Path to Healthy Living Questionnaire) is included in Section 8 (Appendix/Forms). This helps the consume r think about their overall health and lifestyle in order to prioritize goals or begin a discussion with their health care professional. A sample treatment plan with tobacco dependence listed as the problem uded in Section 8 (Appendix/Forms). with relevant goals and objectives is incl Allowing consumers to receive information on the personal consequences of their tobacco use is also an extremely useful techni que used in this manual. This includes feedback of their current exposure to carbon monoxide from smoking, which is easily measured with a hand-held meter. In addi tion to health consequences, consumers may respond with increased motivation to quit when they receive feedback about how much they spend annually to purchase tobacco prod ucts. This information can be explained to the consumer in the assessment session (or Introduction Group) and throughout the treatment. In the first sessions, consumers should be give n a clear idea of what to expect from this group treatment. They should be informed of the number and timing of meetings. It is couraged to attend the group even if they important to tell consumers that they are en are not ready or wanting to quit. The target group size for the group meetings should be about 12-16 members. Group I: “Learning about Healthy Living” Ideally, all smoking consumers with serious me ntal illness are potential candidates for this group treatment. The typical participant should be psychiatrically stable, not in a crisis, and ideally not actively abusing subs tances other than tobacco. Many consumers ession, mood instability or psychosis will have persistent symptoms of depr (hallucinations or delusions) although they are considered stable. These stable symptoms should not be a barrier to atte nding the Learning about Healthy Living treatment groups. Typically consumers may be enrolled in Day Treatment Programs or general outpatient mental health services. Unlike other groups, which rely on participants of the same motivation level, “Group I: Learning about Healthy Living” tional levels. This means accepts smokers of all motiva that the group may be mixed with members who are ambivalent about quitting and even some who may not even express a desire to quit. This is do ne for two reasons: first the treatment itself is motivating and expects to increase each consumer’s desire to quit smoking through successive sessions. Addition ally, we have found that smokers with serious mental illness may not express a de sire to quit. Some may in fact express ambivalence or even deny wanting to quit smoking and yet demonstrate some intent in their actions. It is not uncommon for these consumers to attend and participate in the steps to actively reduce their smoking group sessions. Some may even take further and/or use nicotine replacement. Learning about Healthy Living – Revised 2012 Page | 5

12 SECTION 1: Introduction 2012 Although the lessons follow a sequential se ries and move consumers towards making a quit plan and setting a quit date in Grou p II, some consumers may not attend every rs may join at a later date. session, some may drop out, and othe Group II: “Quitting Smoking” All smokers with a desire to try to quit smok ing in the next month should be appropriate for Group II. Other positive indicators for treatment include a strong desire to stop smoking completely, past quit attempts , willingness to use tobacco treatment medications and willingness to commit to atte nding all group treatment sessions. The type of participants recruited will largely determine the actual success rate achieved in any group, although combination treatmen t of tobacco treatment medications plus counseling are believed to yield the highest su ccess rates. The added treatment effect of the group setting partly comes from seeing others make quit dates and succeed. The facilitator should be careful about including participants in Group II that are clearly stating that they are not ready to quit. Including these participants can contribute to a negative effect on the group, and/or the individual. The Role of Antipsychotics Tobacco dependence in schizophrenia and othe r psychotic disorders are impacted by the pharmacological regimen for psychosis. Trea tment outcomes are enhanced with use of that clozapine treatment is associated with atypical antipsychotics. Past studies found reduced smoking (McEvoy et al., 1995; McEvoy et al., 1999; George et al., 1995). Another study found that subjects receiving other atypical antipsychotics (olanzapine, risperidone, clozapine, and seroquel) had 2-3 times greater success in quitting smoking those on older, traditional antipsychotics (George et al., 2000). Treatment with these dol, has been associated with increased older “typical” antipsychotics, like haloperi consumers the best chance at successful smoking (McEvoy 1995). In order to give quitting, it is preferable that consumers entering a tobacco dependence treatment group are taking an atypical antipsychotic and be on a stable dose of medication for one month prior to starting the treatment. The Important Role of Tobacco Dependence Treatment Medications Tobacco dependence treatment medications ar e a recognized first-line treatment for quitting smoking and other tobacco products. Some of these medications are available over-the-counter (OTC) and others require a prescription. Most treatment guidelines indicate that all smokers trying to quit smoking should use tobacco dependence medications, whenever possible, to lesse n nicotine withdrawal symptoms and make them more successful in their quit attempt (Fiore 2008). Smokers with mental health problems tend to be heavy smokers and are more highly addicted to nicotine than other smokers. This means that it is even more likely that they help them quit smoking. There are will need a tobacco medication treatment to currently seven Food and Drug Administration (FDA) approved pharmacotherapies for tobacco dependence treatment. Five are different types of nicotine replacement Learning about Healthy Living – Revised 2012 Page | 6

13 2012 SECTION 1: Introduction therapies (NRT): nicotine gum, nicotine tran sdermal patch, nicotine lozenge, nicotine inhaler, and the nicotine nasal spray. The two non-nicotine treatments are bupropion SR, (marketed both as Zyban and Wellbutrin ) and varenicline (Chantix). Collectively these seven are considered first line medicati on treatments with established safety and efficacy. These medications are safe and effective and should be considered in the quit plan of all smoking group members. Providing education to your consumers about medications, as well as simple instructions on how to use them are included in Chapters 15 and 16 of this manual. It is important fo r consumers to be able to make choices as to what treatment medication will suit them best. In general, nicotine replacement therapies tend to be under-utilized or used incorrectly, even in the general population. Several of the nicotine medication products are best dosed at frequent intervals (about to use enough nicotine medication will result once an hour) throughout the day. Failure in unpleasant nicotine withdrawal symptoms, which could lead to smoking relapse. For this reason, the group therapis t is advised to oversee and encourage the proper use of nicotine replacement therapy (NRT). NRT sh ould be encouraged inside buildings and during group sessions. Not only does th is support the use of nicotine replacement therapies as a part of the group treatment, b ut it also allows others to become familiar with the products. Other smokers who ma y have been reluctant to try nicotine replacement medications can benefit from th e modeling of seeing other consumers use them successfully. The group can generate questions and discussion about the use of nicotine replacement medications that reinforce the overall treatment. Using nicotine replacement medications is a healthy alternative to smoking that should be rewarded and encouraged whenever possible. A comprehensive chapter with additional information on tobacco dependence treatm ent medications for facilitators and prescribers is included in Section 3. Learning about Healthy Living – Revised 2012 Page | 7

14 SECTION 1: Introduction 2012 Learning about Healthy Living – Revised 2012 Page | 8

15 2012 SECTION 2: Genera l Structure of a Treatment Group General Structure of a Treatment Group Advantages for Treating Smokers in Groups Providing treatment in a group setting has show n to be the most cost and time effective method to help smokers quit and has advantag es over individual sessions. In addition, group members are able to learn from each other, make new friends who are dealing each other. The group meets one time per with similar issues and provide support to week for 20 consecutive weeks. For consistency , it is important to meet on the same day and time each week. This type of treatment approach is most easily integrated into a community mental health or day program setting which uses other curriculum-based treatment approaches. Group treatment is an accepted and familiar form of treatment delivery among consumers struggling with a mental illness. Group treatment provides an added beneficial treatment effect partly from the impact of seeing others succeed and also by being motiva ted to keep up with them. This support is especially helpful to members who are trying to quit smoking to maintain the willpower necessary to get through the difficult first few weeks when craving and withdrawal will be at their worst. In addition to the additional support from a group treatment, group treatment facilitates “peer” pressure and spontaneous modeling of effective coping practiced by other participants. Facilitator-Educator Group Oriented Model Learning about Healthy Living uses a “Facilitator-Educator” group oriented model. In this model, the Facilitator takes an active approach in coordinating the group process and leading discussion. This provides consumers with:  more structure  a specific topic to focus on  and encourages participation by group members. The title Facilitator-Educator implies the dual role of this therapist in enhancing and facilitating discussion as well as providin g a strong educational component to each group session. Utilizing role-plays, giving concrete examples, completing exercises and asking questions that help consumers join in the discussion when capable, allows the facilitator to know if the consumers have gained an understanding of the topic. Validating the consumer’s progress and verb alizing positive affirmations creates a positive, supportive environment. In each group session, facilitators strive for a balance. They must provide education/ information to the group members but in a helpful way so as not to limit the grou p process and to allow for questions and discussions. Although “group-oriented” methods are proven to be successful in helping smokers quit, l needs of the mental health consumer. it is important to understand the specia Learning about Healthy Living – Revised 2012 Page | 9

16 l Structure of a Treatment Group 2012 SECTION 2: Genera Techniques from the 6-session tobacco cessati on group mentioned above (Foulds et al., and included in Group II of this manual. TDP Manual 2004) have been modified Facilitator-Educator As the Facilitator of the “Learning about Health y Living” groups, your role is very crucial ant for you to establish an atmosphere where to the success of the group. It is import consumers know what to expect and will feel safe in the group setting. Every session of ving” groups will follow a the “Learning about Healthy Li ons, Check in with Group Participants, similar format. (i.e. Greeting and Introducti ercises/Role Plays, Closure of Group and Topic Presentation, Followed by Discussion, Ex Encouragement/Reminder to Return Next Week) Being Prepared Before Group Begins Read manual chapter for consumers and co rresponding facilitator guide notes. 1. Prepare all handouts, and/or other supplie s you will need prior to the group. 2. This includes dry erase boards and mark ers, flip charts and pencils for the consumers. 3. Be at the group location a few minutes prior to the start of group. Allow additional time to set up, settle yourself, and be ready to welcome group participants. As a Facilitator 4. Remember that YOU are a ROLE MODEL for the behavior that is expected in your group. Be sure to start and end the group on time. Speak respectfully to consumers and avoid embarrassing group members by challenging them too strongly or putting them on the spot. 5. You are there to facilitate the group! This means...educating the group on various topics, gently guiding participants to stay on track and participate in the discussions. Be sure when introducing a topic, not to over talk! The approach that tends to work best is when consumer s take an active role in their treatment by sharing with each other...not the facili tator doing all the talking! This may need to be modified to adapt to the leve l of functioning of your particular group members, however all group participants should be encouraged to increase their participation over time. When Consumers Arrive at Group 6. As consumers arrive at the group, be su re to portray an optimistic, supportive and encouraging attitude. Being prepared and having organized all the necessary materials you will need in advance, allows you to be totally available to greet your “Hi Joseph, I’m glad you can join us consumers. Using simple greetings like Learning about Healthy Living – Revised 2012 Page | 10

17 SECTION 2: General Structure of a Treatment Group 2012 today” or “Hello Barbara, How are you doing today?” sends a message to that particular consumer that you are glad that they are there. Procedures at Each Group Meeting 7. Basic record keeping should be carried out for each consumer at the start of each group. This should include:  attendance; self-reported cigarettes smoked per day (abbreviated as cpd) in the past  week; self-reported treatment medication use;   expired carbon monoxide (if possible). See Section 8 (Appendix/Forms) for Instructions for Carbon Monoxide Monitoring A sample record sheet (Learning about Heal thy Living Group Record Sheet) is available in Section 8 (Appendix/Forms), which demonstrates one option for recording this information. Consumers should also be give n the opportunity to discuss more personal issues briefly at the end of the group meeting or in separate sessions or by telephone. Introduction of Group The first session is the welcome meeting. To begin, people introduce themselves and state the reason(s) that they have joined th e group. Once introductions are complete, the program is described in some detail to the consumers. Be sure to explain about:  Level of Participation (no one will force them to talk, but members are expected to listen and be respectful of one another)  Mutual Support (group members should be encouraging to one another, respectful of one another, one person talks at a time and no making fun of each other)  Group Ground Rules Be sure to ask participan ts what they think would be reasonable in terms of ground rules. What would make it comfortable for them? If they miss any key points, fill in the blanks by asking, “what about...” Ensure that confidentiality is discussed. Adopt the rules as the guidelines for the group. Ask for a volunteer to write these rules down in large writing, on a flip chart, so that they feel ownership. Have the flip chart for reference at each group meeting. Learning about Healthy Living – Revised 2012 Page | 11

18 SECTION 2: Genera 2012 l Structure of a Treatment Group Below are some standard group rules: Come on time to group each week.   Be respectful of each other.  One person talks at a time.  Be aware of how much time you spend talking to allow others to share.  Confidential Information – what people sh are in the group, stays in the group. Don’t talk to anyone outside the group about what was shared during group.  No fighting or physical touching.  No gossiping about other group members.  If you get angry, try to stay calm. If you need a break, take one. Let the group leader know when you are leaving.  Weekly Topic Sessions/Chapters This manual has been set up to guide facilitators through each group session sequentially. Consumer handouts enhance learning by giving written examples of educational material. Each handout has inte ractive sections for written responses or questions for group discussion. Each Chap ter in the “Learning About Healthy Living” manual has a corresponding section in the Fa cilitator’s Guide. The Facilitator’s Guide lists goals and objectives for that particular group session. Additional techniques and recommendations are included in the sections called Suggested Approach. These are optional ways to expand of the content of your group session by bringing in additional information or using your creativity to enhanc e the learning experience. Although it is recommended that Facilitators follow the suggested format, YOU KNOW YOUR CONSUMERS BEST, and may need to adapt some of the information and exercises to best serve them. Closure of Group It is important to watch the time and allow 10 minutes at the end of group for wrap up. Reassure members that you will be there next week and give them the exact day of week, date and time of group. It may be helpful with some groups to give them a Group Reminder Card (see page below and Section 8) for other appointment card with the next week’s information. Be available at the end of group in the even t that one of the members needs a little bit more time to speak with you or arrang e for an individual time to meet. Learning about Healthy Living – Revised 2012 Page | 12

19 l Structure of a Treatment Group 2012 SECTION 2: Genera Group Reminder Card Group Record Sheet It may be useful to use a single page to document important clinical information about consumers who attended the group session. The Group Record Sheet (see below) is one ch consumer’s progress in a simple way. way to monitor attendance and also track ea Names are entered in the left side column. The baseline assessment information about s per day, cpd), and their expired carbon how much that consumer is smoking (cigarette monoxide reading (CO) is entered. A dated entry is then made for each group attended by that consumer and includes ongoing a ssessments of how much that consumer is smoking (cpd), their expired carbon mono xide reading (CO) and which medications able). A complete version of this form is they are using to try to quit smoking (if applic included in Section 8 (Appendix/Forms). Learning about Healthy Living – Revised 2012 Page | 13

20 l Structure of a Treatment Group 2012 SECTION 2: Genera Tracking Progress The Group Record Sheet is one way to track each consumer’s progress in the Learning about Healthy Living Group through attendan ce and biological (CO) and self-report (cpd) measures of cigarette consumption. An additional way to track progress is to vior, which may occur through participation measure other more subtle changes in beha in this group. Smoking” can be used as an optional A handout entitled “I’m Not Ready to Quit assessment and monitoring tool throughout the group (See Section 8 Appendix/Forms). The purpose of this exercise is to allow lo wer motivated smokers to set goals that are readily achieved through participation in this group. The smoker would read the options and check those goals or activities, which they feel they can commit to. As few e smoker. For example, a smoker who is not as one option may be initially checked by th interested in quitting may agree to attend these treatment sessions and read all the handouts as an initial treatment goal. As th e list progresses, the activities become more active in engaging the smoker to better understand and consider changing behavior patterns, without actually quitting smoking all to gether. In this way, this exercise can be presented at repeated intervals (i.e. monthly) to see if smokers are becoming more interested in quitting. d as a recommended exercise in Chapter 16. This material is also discussed in depth an Learning about Healthy Living – Revised 2012 Page | 14

21 SECTION 3: To bacco Dependence Treatment Medications 2012 Using Pharmacotherapy to Treat Tobacco Dependence in Mental Health Settings The current US Clinical Practice Guidelines indicate that all smokers trying to quit should use pharmacotherapy, except in ca ses where there may be contraindications (Fiore 2008). Pharmacotherapies for tobacco dependence are among the most cost effective treatments in all of medicine and sh ould be considered a first-line treatment. Adding behavioral treatments like group or cognitive-behavioral therapy to medications kelihood of being successful in quitting are effective strategies that double the li smoking, however, pharmacotherapies are effe ctive even in the absence of psychosocial treatment. Almost all smokers can use one or more forms of these pharmacotherapies and there are very few contraind ications to their use. There are currently seven Food and Drug Administration (FDA) approved pharmacotherapies for tobacco dependence tr eatment. Five are different types of nicotine replacement therapies (NRT): nicotine gum, nicotine transdermal patch, nicotine lozenge, nicotine inhaler, and the nicotine nasal spray. The two non-nicotine treatments are bupropion SR, (marketed both as Zyban and Wellbutrin) and varenicline (Chantix). Collectively these seven are conside red first line medication treatments with established safety and efficacy. Rationale to Use Pharmacotherapy There are several reasons to consider using pharmacotherapy to treat tobacco dependence. Research suggests that smoker s with mental illness are a heavy smoking group, with high levels of nicotine dependence (Williams & Ziedonis, 2004). Smokers with mental illness may also have more difficulty quitti ng smoking for a variety of psychological and social reasons. Pharma cotherapies for tobacco dependence can help to reduce or eliminate nicotin e withdrawal, and reduce negati ve mood states associated with quitting. Smokers should not have to suffer with nicotine withdrawal symptoms, which can last for 4 weeks after quitting, wh en treatments are available. Using tobacco treatment medications also blocks the reward or pleasure experienced from smoking. An important rationale to the use of thes they are a proven, e medications is that effective component of treatment. Using medi cations in a quit attempt will double the smoker’s chances of successfully quitting (Fiore 2008). Nicotine Replacement Medications (NRT) The five types of nicotine replacement medica tions (NRT) currently available in the US include three over–the-counter preparations, (nicotine gum, patch and lozenge) and two available by prescription (nicotine inhaler and nasal spray). Nicotine medications are usually started on the day the user stops smoking called the Quit Date. The major indication of NRT is to prevent and trea t the nicotine withdrawal associated with r in effects on withdrawal, urges to smoke, quitting. The five NRT products do not diffe Learning about Healthy Living – Revised 2012 Page | 15

22 bacco Dependence Treatment Medications 2012 SECTION 3: To satisfaction, or rates of abstinence and ab use liability from all are low (Hughes 1989; Hajek 1999; West 2000). They are also all about equally effective and consumer h product or products to use. They do preference may be important in deciding whic differ in their tendency for side effects with the nasal spray producing far more adverse effects than the other forms. The pharmacology and potential for addiction to nicotine is dependent on its route of entry into the body. Smoking delivers the fast est and highest-spiking dose of nicotine to the blood, which is not equaled by any of the nicotine replacement therapy (NRT) medications. Unfortunately smoke in any form is extremely toxic to the body and delivers unwanted chemicals, gases and carcinogens in addition to nicotine. NRT relies on alternate strategies to deliver nicotine al one safely to the body. Nicotine cannot be taken effectively in an oral form like a pill or drink. NRT products get nicotine into the body through the skin (patch), through th e lining of the mouth (gum, lozenge and inhaler) and through the lining of the nose (nasal spray). These methods generally put less nicotine into the body, compared to th e amount delivered from smoking. In addition to the lower delivery of nicotine from NRT products, nicotine medications tend to be under dosed and underutilized. Mo re simply put, people tend to use too little NRT and for too short a time. The lower leve ls of nicotine delivered from NRT explains why these products have very little abuse or addiction potential compared to smoking. It also means that smokers have to be educ ated and counseled to use them properly and for maximum nicotine absorption to occur. Most trials for NRT recommend treatment for 6-12 weeks although some consumers may choose to use the products longer. The long-term health effects of NRT are not definitively known but, if any, are clearly outweighed by the risks from smoking including exposure to carbon monoxide and carcinogens. Psychiatrists and behavioral health specialists can enhance compliance and effectiveness of NRT products by providing brief education and instruction on their use (Williams & Hughes, 2003). This may be of particular importance in consumers with cognitive limitations who are less likely to use instructional booklets or self-help materials effectively. For example, nicot ine absorption in the mouth and cheek is ed with acidic beverages like sodas, coffee, and juices. markedly reduced when NRT is us Simple instructions not to use the gum, lo zenge or inhaler in conjunction with these beverages can greatly increase the nicotine absorption. Nicotine Gum The nicotine gum delivers nicotine to the mouth which is absorbed into the body through the lining of the cheek. Nicotine gum comes in a 2mg and 4mg preparation and those who smoke more than 25 cigarettes pe r day should begin treatment with the 4mg a slow chewing technique called “bite and dose. Absorption of the gum is best with park”. This means that the gum should be chewed slowly and periodically and then held in the cheek to enhance nicotine absorption. The nicotine in the gum emits a peppery Learning about Healthy Living – Revised 2012 Page | 16

23 bacco Dependence Treatment Medications 2012 SECTION 3: To taste, which indicates that nicotine is still left in the product. If the gum is chewed too is likely that nicotine will be swallowed rapidly, like non-medicinal chewing gum, then and the user will experience gastrointestinal upset. Some other possible side effects of , hiccups, nausea, jaw discomfort, or racing the gum include bad taste, throat irritation h and jaws are usually caused by improper heartbeat. Symptoms related to the stomac use of the gum, such as swallowing nicotine or chewing too rapidly. The package insert for the gum recommends chewing 1 to 2 pieces per hour during waking hours. This means that a pack a da y smoker might use 16 pieces of nicotine gum per day plus extra doses for cravings. The most recent data has shown that using more effective than using it only when nicotine gum in a regular (hourly) way is experiencing cravings. An advantage of the nicotine gum is that it is immediate acting, allowing the user to control the nicotine dose. Additional doses can be also be used in situations to cope with cravings. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months. Tapering the amount of gum chewed often helps users stop using it. Long- term physical dependence is one possible disa dvantage of nicotine gum. In fact, research has shown that 15% to 20% of gum users wh o successfully quit smoking continue using the gum for a year or longer. Although th e maximum recommended length of use is 6 to be safer than going back to smoking. months, continuing to use the gum is likely Nicotine Patch Nicotine patches provide a measured dose of nicotine through the skin. As the nicotine doses are lowered by switching patches over a course of weeks, the tobacco user is gradually weaned off nicotine. Patches can be purchased without a prescription. Several types and different strengths are available. Package inserts describe how to use the product as well as special considerations and possible side effects. Nicotine patch is applied only once a day, thus it is the easi est NRT to use and compliance is usually best with the patch. The nicotine patch is typically dosed on a once daily (24 hour) schedule, although it too can be removed at night and dosed on a 16 hour schedule if sleep disturbances occur. The sleep disturbance that is most commonly described is an experience of vivid dreaming. If bothersome to the user, they ca n be instructed to remove the patch before bedtime. The patch is applied to a clean, dry area of the skin without much hair. It is most commonly used on the chest, arm or back. Side effects include skin irritation, and mild redness and itching at the site where the patch was worn. This effect is usually minimal and not a reason to discontinue use of the patch. The skin can appear mildly i rritated (pink) where the patch was worn and can feel itchy or have a slight burning sens ation. The patch should not be placed on irritated skin and the user can use a different skin site each day to minimize irritation. the nicotine replacement patch include: Other possible, but uncommon side effects of Learning about Healthy Living – Revised 2012 Page | 17

24 bacco Dependence Treatment Medications 2012 SECTION 3: To dizziness, racing heartbeat, headache, nausea, vomiting and muscle aches. Nicotine patches, as with other nicotine products, ca n be used safely in smokers with medical disorders including past heart attacks and heart disease but should it is recommended that consumers first discuss this with their doctor. Nicotine absorption from the patch is slow; it takes about 30 minutes for nicotine to get into the blood from the time it is applied to the skin. It takes 2-4 days for steady blood for immediate craving and thus, in clinical levels to be achieved. It is less helpful practice is frequently administered with the nicotine gum, inhaler or nasal spray. Depending on body size, most smokers should start using a full-strength patch (21 mg of nicotine) daily for 4 weeks, and then use a we aker patch (14 mg of nicotine) for another 4 weeks. The FDA recommends using the patch for 3 months. Supplementation of the patch with a second ni cotine product may be helpful in allowing consumers to choose their nicotine dose based on the presence of withdrawal symptoms and may be more effective than patch alone. Nicotine Lozenge Nicotine lozenges are the newest form of over-the-counter nicotine replacement on the market. Nicotine lozenges are not chewed but are held in the mouth and release nicotine as they dissolve. Nicotine lozeng es are pharmacologically similar to the nicotine gum meaning that they are also abso rbed through the lining of the cheek and should not be used with acidic beverages. Possible side effects of the nicotine lozenge include: insomnia (trouble sleeping), nausea, hiccups, coughing, heartburn and headache. As with nicotine gum, the nicotine lozenge is available in two strengths: 2 mg and 4 mg. Smokers determine which dose is appropriate based on how long after waking up they normally have their first cigarette. This is called the Time to First Cigarette or TTFC. Those who smoke within the first 30-minutes of awakening have at least a moderate level of nicotine dependence and should start with the 4mg dose lozenge. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for 3 weeks, and finally, one lozenge every 4-8 hours for 3 weeks. The lozenge manufacturer recommends using it as pa rt of a 12-week quit smoking program. Nicotine lozenge may offer a benefit to those who are unable to use gum due to dental or jaw problems. It can be used more discrete ly than gum, which may offer an advantage to its use in the workplace. Nicotine Nasal Spray The nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the thin lining of the nose. Of all the NRT products, nicotine delivery is most rapid with Learning about Healthy Living – Revised 2012 Page | 18

25 bacco Dependence Treatment Medications 2012 SECTION 3: To the nasal spray, which delivers 1.0 mg of nicot ine per dose (0.5 mg per nostril) dosed up to a maximum of 40 doses per day. This formulation, although producing the greatest tends to have the most adverse effects. peak level of nicotine of all the products, also Many people stop using the nicotine nasal sp ray in the first few days because of these side effects, which can include nasal irri tation, sneezing, runny nose, watery eyes, sneezing, throat irritation and coughing. Also these side effects are common they usually disappear in the first few days of co ntinued use. Providing education about side effects and allowing consumers to try to the nicotine nasal spray during a clinic visit may enhance its use in some smokers. Nicotine nasa l spray is available only by prescription. The nasal spray immediately relieves withdrawal symptoms and provides users with a sense of control over nicotine cravings. Beca use it is easy to use, smokers who keep using it report great satisfaction with it and nicotine nasal spray may offer an advantage to smokers with schizophreni a (Williams et al., 2004). However, the Food and Drug Administration cautions that since this prod uct contains nicotine it can be associated with long term use. se problems may not be able to use the smokers with severe forms of asthma, or no nicotine nasal spray. Nicotine Inhaler The nicotine inhaler is a plastic tube with a replaceable nicotine cartridge inside. When the user puffs on the inhaler mouthpiece, the cartridge provides a nicotine vapor. Unlike other (bronchial) inhalers, which deliver medi cation to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mo uth and is actually an oral puffer. Nicotine is absorbed through the lining of the mo uth, similar to the gum and lozenge. Each inhaler cartridge can be used for a 20 -60 minute period and considerable puffing is needed for maximal absorption (400 p uffs per inhaler). The most common side effects, especially when first using the inha ler, include coughing, throat irritation and upset stomach. The recommended maximum daily dose is 16 cartridges per day. Deep puffing is not recommended and can lead to increased cough and throat irritation. Development of the inhaler intended to addr ess not only nicotine pharmacology but also the sensory and ritual aspects of holding th e device, which looks like a thick plastic cigarette. As with the other nicotine replac ement treatments, little abuse or dependence haler is available only by prescription. of the inhaler has been reported. The nicotine in Learning about Healthy Living – Revised 2012 Page | 19

26 bacco Dependence Treatment Medications 2012 SECTION 3: To Bupropion Bupropion SR (Zyban or Wellbutrin) is an approved prescription treatment for both Psychiatrists and other physicians have major depression and tobacco dependence. prescribed it for years to treat depression and it is a safe and effective medication. Bupropion SR was later discovered to help people quit smoking by reducing their craving for cigarettes and nicotine withdrawal. Bupropion SR (generic name) is EXACTLY the SAME medication as Wellbutrin SR or Zyban. Using bupropion to quit smoking doubles the success rate of quitters compared to placebo. Bupropion can only be taken with a doctor’s prescription. It is usually started about two weeks before the Quit date. Most people start at a dose of 150mg per day for the first week and then increase to a dose of 300mg per day in the second and subsequent weeks. It is recommended that users continue taking bupropion SR for at least 12 weeks (3 months) after quitting smok ing. People who use bupropion when they quit smoking gain less weight than those who quit without medication (Hurt et al.,1997). The most common side effects of bupropio n include anxiety, restlessness, lowered appetite, dizziness, dry mouth, headache, or insomnia. Many people do not experience any side effects from taking bupropion. An infrequent but clinically important adverse reaction to bupropion includes an increased ri sk of seizures. For that reason, bupropion should not be prescribed in anyone with known seizures or bulimia (binge and purge eating disorder). It should also be used wi th caution in smokers with a history of head e. It should not be taken with alcohol or trauma who may be at increased risk for seizur in combination with these substances. All other street drugs, since it can cause seizures antidepressants, including bupropion, should be used with caution in smokers with bipolar disorder or a history of manic episodes since it can worsen these conditions. Bupropion can be used alone or together with nicotine replacement. Bupropion is not depression, it can be effectively used to addicting or habit forming. For smokers with treat both problems. It can also be sa fely combined with SSRI antidepressants. Bupropion SR works to help all kinds of people quit smoking. It helps people who have a history of depression and those who do not. Sometimes it even helps people who have not been able to quit on it in the past. Th is means that a re-trial of Bupropion SR might be helpful to some people who have tried it before. Varenicline Approved by the FDA in 2006, Varenicline is the first nicotinic acetylcholine receptor partial agonist to be developed for smoking ce ssation. Varenicline is highly selective for the α 4 β 2 nicotinic acetylcholine receptor, which is responsible for mediating the reinforcing properties of nicotine in the brain. Simply put, it’s thought to help people quit smoking by mimicking the dopamine effects of nicotine to reduce withdrawal symptoms. In addition, in the presence of ni cotine, varenicline blocks nicotine binding, and therefore, blocking nicotine’s ability to cause reward or pleasure. This second Learning about Healthy Living – Revised 2012 Page | 20

27 bacco Dependence Treatment Medications 2012 SECTION 3: To mechanism of action is especially important as it may prevent a slip from becoming a rived from smoking. The drug is marketed full relapse by decreasing the satisfaction de and distributed by Pfizer under the trade name Chantix. und and the compound is excreted primarily Varenicline is not significantly protein bo The approved dosing regimen in adults is 1 mg twice daily for 12 unchanged in the urine. weeks (renewable for another 12 weeks), starting with a 1-week titration. Several trials have shown that varenicline is ef ficacious for smoking cessation. Varenicline increases eefold as compared with placebo and by 50% the chances of quitting smoking nearly thr as compared with sustained-release bupropio n (Gonzales et al., 2006; Jorenby et al., 2006). Nausea is the most preval ent dose-dependent side effect, b ut generally mild and not leading to drug discontinuation . Other common side effects include abnormal dreams, insomnia, and constipation. In 2009, the FDA issued labeling updates du e to concerns that varenicline might cause serious neuropsychiatric adverse events, base d on case reports. The FDA’s preliminary assessment revealed that many of the ca ses reflect new-onset of depressed mood, suicidal ideation, and changes in emotion and behavior within days to weeks of initiating varenicline treatment. The role of varenicline in these cases is not clear because smoking cessation, with or without treatment, is associated with nicotine withdrawal symptoms and has also been associ ated with the exacerbation of underlying psychiatric illness. On its website the FDA acknowledges the limi tations of case reports including the lack of medical validation, possibl e influence by the media and other sources, potential for errors in reporting and possible complication of nicotine withdrawal symptoms. For these reasons systematically collected data from prospective or retrospective data sets can be invaluable in assessing true risk ass ociated with use of varenicline. Research data from several studies has now been pu blished; including post-hoc analyses from larger samples of smoking cessation studies as well as pilot safety studies to examine es have not shown an association between this prospectively. Most of these analys depression or other psychiatric worsen ing during varenicline treatment. ctive treatment in a broad range of tobacco Varenicline has been shown to be an effe users with medical, behavioral, and diverse demographic characteristics. The recent studies finding excellent safety and efficacy in groups of smokers with diseases including chronic obstructive pulmonary disease and cardiovascular disease are particularly encouraging and call for increased use of this medication for smoking cessation (Williams et al., 2011c) Combinations of Medications Clinicians also should consider the use of certain combinations of tobacco treatment medications identified as effective in the PHS Clinical Practice Guideline for Treating at the combination of long-term nicotine Tobacco (Fiore 2008). Studies have found th patch use + ad libitum short-acting nicotine replacement therapy (NRT) is more Page | 21 Learning about Healthy Living – Revised 2012

28 bacco Dependence Treatment Medications 2012 SECTION 3: To effective than a single NRT (example: patc h alone). Any of the short-acting NRTs (gum, lozenge, inhaler or nasal spray) can be used in combinations with the nicotine patch. Also, there is evidence that com bination NRT therapy may be particularly effective in suppressing tobacco withdrawal symptoms. Thus, it may be that NRT combinations are especially helpful for hi ghly dependent smokers or those with a history of severe withdrawal. Bupropion can also be given safely in combination with NRT although it is generally NOT recommend ed to give combinations of nicotine and varenicline. Varenicline is not recommended for use in combination with NRT because its nicotine antagonist properties can increase side effects (nausea) and may provide no additional benefit with nicotine medications. A large randomized placebo-controlled clinical trial of five smoking cessation pharmacotherapies (nicotine lozenge, nicotine patch, bupropion SR, nicotine patch + e or placebo) showed that the combination nicotine lozenge, bupropion + nicotine lozeng of nicotine patch plus lozenge produced the hi ghest abstinence rates at 6 months (Piper et al., 2009). Conclusion Tobacco dependence is a treatable disorder, wh ich has been overlooked by psychiatrists and behavioral health specialists. The seve n available pharmacotherapies are safe and effective in the general population and should be used more aggressively in persons with a mental health or addictive disorders. Studies of these populations are extremely limited and warrant further research to opti mizing currently available treatments and explore new ones. Consumers and their families should be educated about the considerable risks of smoking and about the benefits of tobacco dependence treatment. All mental health consumers deserve access to smoking treatments, which have been proven effective in carefully designed stud ies. Educating psychiat rists and behavioral health specialists about incorporating tobacco treatment into their usual practice will be an important step in bringing more consumers into treatment and thereby prolonging their lives. Unfortunately, there are no well-accepted algorithms to guide optimal so the decision will need to be made selection among the first-line medications considering patient preference, side effects and cost. Learning about Healthy Living – Revised 2012 Page | 22

29 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go Group I: “Learning ab out Healthy Living” Goals, Objectives and Suggested Approaches Ideally, all smoking consumers with serious me ntal illness are potential candidates for this group treatment. The typical participant should be psychiatrically stable, not in a crisis, and not actively abusing substances other than tobacco. Many consumers will have persistent symptoms of depression, m ood instability or psychosis (hallucinations or delusions) although they are considered st able. These stable symptoms should not be a barrier to attending the Learning about He althy Living treatment groups. Typically consumers may be enrolled in Day Treatment Programs or general outpatient mental health services. Unlike other groups, which rely on partic ipants of the same motivation level, “Group I: Learning about Healthy Living” accepts smokers of all motivational levels . This means that the group may be mixed with members who are ambivalent about quitting and even some who may not even expre ss a desire to quit. This is done for two ting and expects to increase each client’s reasons: first the treatment itself is motiva desire to quit smoking through successive sessions. Additionally, we have found that smokers with serious mental i to quit. Some may in fact llness may not express a desire express ambivalence or even deny wanting to quit smoking and yet demonstrate some intent in their actions. It is not uncommon for these consumers to attend and participate in the group sessions. Some may even take further steps to actively reduce their smoking and/or use nicotine replacement. Although the lessons follow a sequential se ries and move consumers towards making a quit plan and setting a quit date in Grou p II, some consumers may not attend every session, some may drop out, and othe rs may join at a later date. Introduction: Welcome to the Healthy Living Group (Consumer’s Handouts Sect ion 5: Introduction) Objectives for Introduction:  Welcome consumers to the Learning About Healthy Living Group.  Educate the consumers about the overall content of the Learning About Healthy Living Group.  Allow group members to begin to get to know the Facilitator and each other. After reading this section, in dividuals will be able to: portant to them to consider during the  Think about what health issues will be im course of the group. Learning about Healthy Living – Revised 2012 Page | 23

30 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go  Describe guidelines that will make the gr oup setting a safe place to learn about the “Learning About Healthy Living” program. Suggested Approach:  It will be important for the Facilitato r to be warm and welcoming to group members upon arrival to create a non-threatening environment.  Allow participants to introduce themselves to the group.  Discuss rules for expected behavior during group sessions (See also Section 2).  Although a good portion of this manual’s focus is on helping consumers look at their tobacco usage, this could be very threatening initially to the consumer who smokes. It will be important during the Healthy Living approach to emphasize tobacco but the manual also includes topics on healthy eating, increasing physical activity and dealing with stress. Throug hout the group sessions, it may be helpful to discuss “unhealthy” ways that people may deal with other problems including stress and mental illness sy mptoms. (i.e. yelling, violence, alcohol, tobacco, food, rately discusses the relevant risks from etc.). In this way, this approach accu smoking and also presents a hopeful and healthy alternative. Chapter 1: Starting on the Road to Healthy Living (Consumer’s Handouts Section 5: Chapter 1) Objectives for this Chapter:  Help consumers understand that healthy living is an attainable goal that can help them to feel better in many ways.  Educate the consumers about the importance of looking at their overall wellness and tobacco use as part of their recovery from mental illness.  steps towards healthier living. Identify ways to begin to take dividuals will be able to: After reading this section, in e group and evaluating various parts of  Identify the importance of attending th their general emotional and physical health.  Describe what health issues will be im portant to them to address during the course of the Learning about Healthy Living group. Learn more about their overall health status.  Learning about Healthy Living – Revised 2012 Page | 24

31 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go Suggested Approach: Allow participants to discuss which st eps towards healthier living they can  gnificance of calling the session title consider. Ask group members about the si “Starting on the Road to Healthy Living”. This name is symbolic in describing that having a healthy life is a process that will not happen overnight yet can be achieved in many small steps.  Recognize that it is hard to make any li festyle changes and that it is helpful to think about it as acquiring a new skill that requires some effort and practice to get it right.  Additional activities include an assessm ent of weight and body mass index for participants (See Section 8 Appendix/For ms). Elevated body mass index is associated with poor health and condition s such as diabetes and hypertension. This may best be done on an individual basis. A nurse may be very helpful in performing these assessments and giving feedback to consumers. onnaire is also included as a resource The On the Path to Healthy Living Questi  for consumers to fill out (See Section 8 Appendix/Forms). It is a more comprehensive evaluation of physical health, weight/nutrition, smoking and physical activity, sleep and stress reduct ion that may take more time than the group allows. It helps the consumer iden tify areas to work on and allows the facilitator to have a better understandin g of the complete health and wellness of the individual. Chapter 2: Why is smoking dangerous? (Consumer’s Handouts Section 5: Chapter 2) Objectives for this Chapter: Educate the group about the risks of lung and heart disease and that nearly all  cases of lung cancer are related to smoking.  Educate the group that smoking is link ed to other consequences, including missing work due to increased illnesses. After reading this section, in dividuals will be able to:  Understand the negative health consequences caused by smoking. they have which may be caused by their  Identify any illnesses or symptoms that smoking. Suggested Approach: Page | 25 Learning about Healthy Living – Revised 2012

32 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go  After reading these pages, encourage individuals to talk about their understanding of smoking as a danger to their health. Discuss any physical symptoms or medical problems the consumers have related  to smoking (i.e., shortness of breath, di fficulty walking, coughing up phlegm). sses and clear hair gel which shows how  Make a phlegm and tar jar out of mola much a pack a day smoker collects in their bodies. Chapter 3: What’s in cigarette smoke? (Consumer’s Handouts Section 5: Chapter 3) Objectives for this Chapter:  Educate the group about the chemicals in cigarette smoke.  Educate the group that nicotine is not a carcinogen, or cancer-causing chemical, although it is the addicting part of a cigarette. After reading this section, in dividuals will be able to: Understand that the chemicals in burning cigarette smoke are dangerous to their  health.  Identify that some of these chemicals ar e used in other products that they are familiar with and are very toxic. Suggested Approach:  After reading these pages, encourage individuals to talk about their understanding of smoking as a danger to themselves and others. Encourage participants to discuss ho  w chemicals in burning cigarettes are harmful. Chapter 4: Why do so many consumers wi th mental illness smoke? (Consumer’s Handouts Sect ion 5 : Chapter 4) Objectives for this Chapter:  To understand that mental illness and smoking are linked.  To recognize that smoking is a complex problem made of biological, psychological and social factors. After reading this section, in dividuals will be able to: Page | 26 Learning about Healthy Living – Revised 2012

33 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go  Understand that smoking is a prob lem which has vari ous factors which contribute to why smokers begin and then continue smoking.  Recognize that in addition to physical fa ctors that having confidence that you can quit and being surrounded by other smokers also contribute to smoking behavior. Suggested Approach:  Discuss how smoking in the environment k eeps others from being able to quit smoking.  Ask group members how they feel about different factors and which they feel contribute most in their smoking. Chapter 5: What is carbon monoxide? (Consumer’s Handouts Sect ion 5: Chapter 5) Objectives for this Chapter:  Educate the group on the health risks of carbon monoxide.  Give feedback to group members on their own carbon monoxide level and associated risks. After reading this section, individuals will: Know what carbon monoxide is and why it is so dangerous to their health.  Know their own CO level and what level of  health risk they are at in relation to their CO level.  Understand that their CO level will quickl y go down to safe levels by quitting smoking. Suggested Approach:  After reading these pages, encourage indi viduals to talk about their knowledge about carbon monoxide before this class. Take a CO level of everyone in the group and give them an idea of what their CO  level indicates regarding health risk factors.  Discuss how quitting smoking will quickly make their CO level return to zero. Supplementary/ Other discussion information:  Most people now have carbon monoxide detectors in their homes like smoke detectors to alert them if this poison is in the air in dangerous levels. Section 8 Appendix/Forms) Carbon Monoxide Meter* (See  Page | 27 Learning about Healthy Living – Revised 2012

34 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches  A carbon monoxide meter measures the amount of carbon monoxide in the body. Carbon monoxide in cigarettes is harm ful to your body at any level.  even at lower levels can lead to  Long-term exposure of carbon monoxide heart disease and heart attacks.  The normal level of carbon monoxide in the blood for a non-smoker is usually between 0 and 8 ppm (parts per million).  Smoking one pack of cigarettes a day will result in a carbon monoxide level of about 20 ppm. *It is strongly recommended that facilities purchase a carbon monoxide monitor to measure their consumer’s co reading. This reading can be a motivator for your couraging them to quit. This cost of a consumer in tracking their progress and en carbon monoxide monitor ranges in price from $600 to $1500. Chapter 6: How much does smoking cost? (Consumer’s Handouts Section 5: Chapter 6) Objectives for this Chapter: s on a regular basis can add up.  To learn that buying small item  To learn that smoking is expensive.  hly and annual amount that they spend To learn the average daily, weekly, mont on cigarettes. After reading this section, in dividuals will be able to:  Understand that a pack a day smoker spends almost $2000 per year on cigarettes.  Learn how much money they will save if they quit smoking and other things they will be able to buy for themselves with that extra money. Suggested Approach:  Discuss how much group members spend on other necessities including rent and food and compare the amount of income spent on cigarettes.  Share with the group that research ers have found that smokers with schizophrenia spend more than 27% of their monthly income on cigarettes – ask if they think they have purchased ci garettes at times instead of food.  Brainstorm how members would like to sp end their money on other things in the future. Learning about Healthy Living – Revised 2012 Page | 28

35 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go Chapter 7: How does tobacco advertising affect us? (Consumer’s Handouts Section 5: Chapter 7) Objectives for this Chapter: ffective in getting people to smoke.  To learn that tobacco advertising is e To learn that everyone can be a target for advertising.  After reading this section, in dividuals will be able to:  her alternative forms of tobacco do not Understand that light cigarettes and ot have fewer health risks. Identify that the tobacco companies use advertising to try to trick consumers into  friends, look sexy, and attract dates. believing that smoking makes them have Suggested Approach: Ask group why cigarette ads do not show real smokers with diseases, in the  hospital, with oxygen tanks, etc.  Distribute magazines to group member s and have them look for tobacco ads (fashion, sports and celebrity magazines have tobacco advertising). Chapter 8: Second-Hand Smoke? (Consumer’s Handouts Section 5: Chapter 8) Objectives for this Chapter:  Educate the group about second-hand smoke. Inform the group how smoke is dangerous even to non-smokers.  dividuals will be able to: After reading this section, in  Understand why exposure to second-hand smoke is dangerous for even non- smokers. Suggested Approach: ey were around when they were younger  Ask participants to talk about people th (i.e. parents, grandparents, siblings) that smoked. Did they have ear infections or colds on a regular basis as a child? Page | 29 Learning about Healthy Living – Revised 2012

36 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go  Encourage participants to talk about pe ople who are around them now that can be affected by their smoking. Other discussion information:  Recent research studies have shown that even a half-hour of second-hand smoke exposure causes heart damage and can ca use heart attacks in people with known heart disease. Chapter 9: How are my medications affected by smoking? (Consumer’s Handouts Section 5: Chapter 9) Objectives for this Chapter:  To learn about how the blood levels of some medications are lowered in smokers.  To identify medications which are affected by smoking. After reading this section, in dividuals will be able to: treat mental illness are taken out of Understand that many medications used to  the body (metabolized) faster in smokers.  Understand that smokers end up on high er medication doses because of this interaction. Suggested Approach:  Help group members identify if their medications are impacted by this system.  Encourage group to talk about medication s and doses with their doctor if they have other questions. Alert group to inform their doctor if they  are thinking about quitting smoking. The same effect, which lowers medication levels in smokers, can also lead to higher than normal medication levels if smoking is abruptly stopped. Since any sudden changes in smoking could impact on medications, the group should be alerted for changes in side effects that could occur.  Reinforce to the consumers that having their medications at the correct dose keeps them stable.  Discuss how it might be possible for indi viduals to have their medication dose reduced if they quit smoking successfully.  Remind group that stopping or changi ng your medication suddenly could be dangerous and strongly advise against this. Learning about Healthy Living – Revised 2012 Page | 30

37 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches Other discussion information: gan for purifying the body. By working Explain that the liver is an important or hard to remove harmful chemicals and toxins from the body, the liver can keep the body in a normal balance. The li ver contains thousands of enzymes that destroy specific toxins in the body. Wi thout these important enzymes, the body would not be able to rid itself of toxins . Even medications that we use to treat disease are removed from the body in this way. Tars in cigarette smoke “turn on” a part of the liver system. This means that in a smoker, this enzyme works faster and better than usual. The effect of having a faster and better working the body faster than normal. The name enzyme is that it takes medications out of of the enzyme is cytochrome (p450) 1A2 isoenzyme. Chapter 10: Why are cigarettes addictive? (Consumer’s Handouts Section 5: Chapter 10) Objectives for this Chapter:  Educate the group that nicotine is the addicting component of cigarettes.  Educate that although nicotine is present in some medications, that these are safe to use and not addicting like cigarettes. After reading this section, in dividuals will be able to: found in tobacco that is addicting. Understand that nicotine is the chemical   Understand that having withdrawal symptoms is physical eviden ce that they have an addiction to nicotine.  Recognize that most people continue to sm oke even though they know it is bad for them. Suggested Approach:  Talk about what it means to be addicted  Encourage group members to discuss how they overcame addictions to other substances and relate the recovery from nicotine addiction in similar terms.  Discuss how having an addiction does no t mean you are a bad or weak person. Many smokers continue to smoke although they have health consequences due to the addicting properties of cigarettes. Addiction is a health problem that needs treatment. Other discussion information:  The body metabolizes nicotine in a few hours, making its effect very short acting. veral times a day to keep the effect of This explains why smokers need to smoke se Learning about Healthy Living – Revised 2012 Page | 31

38 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go nicotine from wearing off or immediately en they wake up wanting a cigarette wh in the morning.  Although nicotine is addicting it is not a carcinogen or cancer-causing chemical. Many of the other components of toba cco smoke are far more dangerous than nicotine. This explains why we can safe ly use nicotine as a medication to help people. Chapter 11: What are my smoking patterns? (Consumer’s Handouts Section 5: Chapter 11) Objectives for this Chapter:  To understand that smokers have usual patterns of smoking, which are the times, situations, actions and things th at make them want to smoke. After reading this section, in dividuals will be able to: Understand that smokers have patterns of usual behaviors that are linked to  smoking. These common situations, almo st automatically encourage someone to have a cigarette.  Recognize and identify their most common smoking patterns. Suggested Approach:  Have each group member name a time an d/or behavior that they always do when they light up their cigarette. Encourage others to identify similar behaviors.  Discuss which smoking patterns would be easy or hard to change.  Suggest that group members try to change one smoking pattern that they are currently doing. All group members to help make suggestio ns on what else the person can do  to break that smoking pattern. Chapter 12: How can I better manage stress? (Consumer’s Handouts Section: Chapter 12) Objectives for this Chapter:  Discuss better ways to hand le stress that can be incorporated into all of our lifestyles. Learn a new skill for stress management: deep natural breathing.  Learning about Healthy Living – Revised 2012 Page | 32

39 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches dividuals will be able to: After reading this section, in Identify that smoking has not always b een a helpful way to deal with stress.  Understand how deep natural breathing ca n help them to reduce stress and feel  better. Suggested Approach:  Practice deep breathing exercise while in the group session. with stress, or other stress management  Ask group to share other suggestions to deal while in the group setting if possible. techniques and practice them with consumers Chapter 13: How much physical activity do I need? (Consumer’s Handouts Section 5: Chapter 13) Objectives for this Chapter: be incorporated into all of our lifestyles. Discuss physical activity options that can   Learn the benefit of increasing physical activity. After reading this section, in dividuals will be able to:  Think of a few ways that they can increase physical activity.  Understand how increased physical acti vity could help them emotionally and physically. Suggested Approach:  Have class go outside and walk briskly fo r 5 minutes together and afterwards talk about how that felt and how they feel emotionally and physically after they’ve cooled down.  Have group members who currently exercise regularly share about how initially it was difficult to begin, but that sticking to their plan made them feel better and it became part of their everyday routine. Chapter 14: How can I make healthier food choices? (Consumer’s Handouts Section 5: Chapter 14) Objectives for this Chapter: Teach consumers about healthy food options.  Learning about Healthy Living – Revised 2012 Page | 33

40 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches  List some do’s and don’ts regarding a healthy diet.  Teach consumers that quitting smoking is healthier than gaining a small amount of weight. After reading this section, in dividuals will be able to:  List some foods that are healthy to eat.  Know some guidelines to follow for a healthy diet.  List some options to limit weight gain. Suggested Approach: Have consumers list their favorite food s and then try to come up with healthy  alternatives for those foods:  popcorn for potato chips  pretzels for potato chips  diet soda for regular soda  slice of pizza for fast food  low-fat yogurt for ice cream not a good idea soon after a stop smoking Discuss why severe or “crash dieting” is  quit attempt.  Have consumers discuss concerns about weig ht gain that may be stopping them from trying to quit smoking. Chapter 15: Why should I quit smoking? (Consumer’s Handouts Sect ion 5: Chapter 15) Objectives for this Chapter: To review the short and long term benefits of quitting smoking.   To build motivation towards thinking about joining the next quit smoking group. dividuals will be able to: After reading this section, in  To review the negative consequences of smoking that were learned in earlier chapters.  To begin to look at their decision to smoke and recognize: o What they like about smoking. o What they don’t like about smoking. o What their fears are about quitting. What would be good if they quit smoking. o Learning about Healthy Living – Revised 2012 Page | 34

41 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go Suggested Approach: Encourage group members to discuss both pros and cons of continuing to smoke  Discuss how making a decision al balance can help someon e to make a decision by  looking objectively at two sides of an issue.  Using the decisional balance exercise is a component of a motivational intervention. Chapter 16: What if I’m not ready to quit? (Consumer’s Handouts Section 5: Chapter 16) Objectives for this Chapter:  To recognize that everyone is not read y to quit smoking at the same time.  To encourage those smokers who are not ready to quit smoking to continue to learn about their smoking by remaining in this educational group. After reading this section, in dividuals will be able to: To understand that even if smokers are not ready to quit smoking at this time,  that they can benefit from learning more about the effects of their smoking on their health and may want to consider quitting in the future.  Talk about their own concerns/ambivalence about quitting. Suggested Approach:  Encourage group members to discuss an y ambivalence they may have about quitting smoking and what might help them make the decision to quit in the future.  Encourage smokers who do not want to quit to stay in the group. Group members who are more motivated towards quitting may be able to share their ideas with lower motivated members.  Help the group identify positive steps they can take in their treatment even if they are not ready to quit smoking. Chapter 17: Is it really possible fo r me to quit smoking? (Consumer’s Handouts Sect ion 5: Chapter 17) Objectives for this Chapter: To encourage smokers to develop new, alternate coping skills.  Learning about Healthy Living – Revised 2012 Page | 35

42 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go After reading this section, in dividuals will be able to: To review a list of new coping strategies for dealing with stressful situations.   Understand that they should choose what coping strategies they feel will work best for them, then try it instead of smoking Suggested Approach:  Ask group if they are satisfied using sm oking as their main/ only/ primary coping mechanism.  Discuss how it will feel to try new coping strategies.  Encourage group to review list of new copin g skills or think of others that they would like try. Chapter 18: What happens when I quit smok ing without help? (cold turkey) ion 5: Chapter 18) (Consumer’s Handouts Sect Objectives for this Chapter: To teach group that quitting cold turkey causes many unpleasant withdrawal  symptoms. After reading this section, in dividuals will be able to: Understand that most smokers have a physical addiction to smoking.   Recognize that when they stop smokin g, that they will develop nicotine withdrawal symptoms. Suggested Approach:  Ask group how it felt to experience nicotine withdrawal.  Help group to understand that nicotine withdrawal can be prevented or minimized if they use medica tions for future quit attempts. Chapter 19: How do medications help me quit smoking? (Consumer’s Handouts Section 5: Chapter 19) Objectives for this Chapter: To teach group about the 7 medications th  at are available to help them stop smoking. Learning about Healthy Living – Revised 2012 Page | 36

43 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go  To understand that medications are safe and effective and make someone twice as likely to be successful in quitting smoking. After reading this section, in dividuals will be able to:  Identify the medications which are effect ive and available for quitting smoking.  Learn different characteristics of the nicotine replacement treatment and other medications that help you to quit. Suggested Approach:  Discuss the past experiences that the gr oup has had with medications. If the experiences have not been positive, ask members how long they used medications and if it was in conjunction with psychosocial treatment. Smokers are encouraged to try something new if they think it will work for them, but even a retrial of a medication can be effective. Better compliance or using a medication as part of a comprehensive treatment a pproach, can make it more effective. How Nicotine Replacement Works   Nicotine medications treat nicotine withdrawal symptoms and nicotine cravings. These are difficult symptoms that 70% to 90% of smokers say is their only reason for not giving up cigarettes.  By using a nicotine medication, a sm oker's withdrawal symptoms are reduced. Lack of success is often related to the onset of withdrawal symptoms. By reducing these symp toms with the use of nicotine replacement therapy, smokers who want to quit have a better chance of being successful.  For smokers, nicotine blood levels will vary, depending on individual smoking patterns such as the time between cigarettes, how deeply the person inhales, the number of cigarettes smoked per day, and the brand smoked. Smoking delivers nicotine to the bloodstream very quickly - within a few seconds. Nicotine replacements generally work more slowly, and the amount of nicotine in the bloodstream is less than that from smoking. That makes nicotine medica tions much safer for the body, with fewer health risks and also much less addicting than cigarettes.  The most effective time to start nicotine replacement is at the beginning of an attempt to quit. Often smokers first try to quit on their own, and then decide to try nicotine replacement. Never use nicotine replacement therapy if you plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to your health.  Smokers who are pregnant or have heart disease should consult with their doctor before using over the counter nicotine replacement. Learning about Healthy Living – Revised 2012 Page | 37

44 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches  Some people use Bupropion, a non-nicotine medication to help them quit smoking. Bupropion can be used al one or in combination with nicotine chances of quitting. It is usually a replacement medications to improve your cations, some people use varenicline, personal choice to use non-nicotine medi others use non-nicotine medication to help them quit. Varenicline is effective at duces the pleasure associated with eliminating nicotine withdrawal and re smoking cigarettes. Some people are unable to take nicotine or prefer to take a pill medication to help them quit smoking. Chapter 20: Which medications should I use? (Consumer’s Handouts Section 5: Chapter 20) Objectives for this Chapter:  will help them to decide which To provide group with information that medications are best for them to use. After reading this section, in dividuals will be able to: of the tobacco treatment medications. Understand some key aspects of each   Recognize which medications are available over the counter and which need a doctor’s prescription  New evidence suggests varenicline is more effective than the other medications. Suggested Approach:  This group may require 2 sessions to cover all the medications information.  Help group to understand that all medications are effective and that personal choice is a factor.  Have group do a role play in which they request a prescription for nicotine inhaler, bupropion or varenicline from their doctor.  See also Section 3 for more information on tobacco dependence treatment medications. NOTES FOR INSTRUCTORS Descriptions of Various Medications Nicotine Patch: Patches provide a measured dose of nicotine through the skin. Over the course of weeks, , you can lower the doses of nicotine the by switching the patch to a lower strength Learning about Healthy Living – Revised 2012 Page | 38

45 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go person receives. Slowly the tobacco user is weaned off nicotine. Patches can be purchased without a prescription. Several ty pes and different strengths are available. oduct as well as special considerations and Package inserts describe how to use the pr possible side effects.  The 24-hour patch provides a steady do se of nicotine, avoiding peaks and troughs. It helps with early morning wi thdrawal. However, there may be mild side effects such as disrupted sl eep patterns and skin irritation.  ers should start using a full-strength Depending on body size, most tobacco us patch (21 mg of nicotine) daily for 4 weeks, and then use a weaker patch (14 mg of nicotine) for another 4 weeks. The patch should be applied in the morning to a clean, dry area of the skin  without much hair. It should be placed below the neck and above the waist - for example, on the arm, chest or back.  The FDA recommends using the patch for 3 months.  Side effects of the patch are usually limi ted to the skin where the patch is applied and are minor. The skin can appear mildly irritated and can feel itchy or have a slight burning sensation. the nicotine replacement patch include: Other possible but unusual side effects of  dizziness, racing heartbeat, sleep prob lems, headache, nausea, vomiting and muscle aches. Nicotine Gum: the gum to the patch. Another advantage of If you have sensitive skin, you may prefer nicotine gum is that it allows you to control the nicotine do ses. The gum can be chewed as needed or on a fixed schedule during th e day. The most recent data has shown that scheduled dosing is more effective. A schedule of 1 to 2 pieces per hour is common. On the other hand, with an as-needed schedule, you can chew more nicotine during a craving.  If you smoke a pack or more per day, smok e within 30 minutes of rising, or have trouble not smoking in restricted areas, you may need to start with the higher dose (4 mg).  No more than 20 pieces should be us ed in one day. Nicotine gum is usually recommended for 1 to 3 months, with the maximum being 6 months.  Tapering the amount of gum chewed may help you stop using it.  Some possible side effects of the gum: bad taste, throat irritation, hiccups, nausea, jaw discomfort, or racing heartbeat. Symptoms related to the stomach and jaws are usually caused by improper use of the gum, such as swallowing nicotine or chewing too rapidly.  Long-term dependence is one possible di sadvantage of nicotine gum. In fact, gum users who successfully quit smoking research has shown that 15% to 20% of continue using the gum for a year or longer. Although the maximum Learning about Healthy Living – Revised 2012 Page | 39

46 SECTION 4: Group I - Facilitators Guide 2012 als, Objectives & Suggested Approaches Go recommended length of use is 6 months, cont inuing to use the gum is likely to be safer than going back to smoking. But sinc e there is little research on the health effects of long-term nicotine gum use, most health care providers still recommend limiting its use to 6 months. Nicotine Lozenge: acement on the market. As with nicotine These are the newest form of nicotine repl gum, the nicotine lozenge is available in two strengths: 2 mg and 4 mg. Smokers determine which dose is appropriate for them based on how long after waking up they normally have their first cigarette. If they smoke within the first 30-minutes of awakening, start with the 4mg lozenge.  The lozenge manufacturer recommends usin g it as part of a 12-week program. The recommended dose is one lozenge every 1-2 hours for 6 weeks, then one lozenge every 2-4 hours for 3 weeks, and finally, one lozenge every 4-8 hours for 3 weeks.  Possible side effects of the nicotine lozeng e include: insomnia (trouble sleeping), nausea, hiccups, coughing, heartburn and headache. Nicotine Nasal Spray: The nasal spray delivers nicotine quickly to the bloodstream as it is absorbed through the nose. It is available only by prescription.  The nasal spray immediately relieves wi thdrawal symptoms and offers you a sense of control over nicotine cravings. Beca use it is easy to use, smokers report great satisfaction.  However, the Food and Drug Administrati on cautions that since this product contains nicotine, it can be associated with long term use.  It recommends the spray be prescribed for 3-month periods and should not be used for longer than 6 months. The most common side effects last about 1 to 2 weeks and can include the  following: nasal irritation, runny nose, wa tery eyes, sneezing, throat irritation and coughing. Nicotine Inhaler: Introduced in 1998, inhalers are available on ly by prescription. Th e nicotine inhaler is a plastic tube with a nicotine cartridge inside. When you puff on the inhaler, the cartridge provides a nicotine vapor. Unlike other inhale rs, which deliver most of the medication to the lungs, the nicotine inhaler delivers most of the nicotine vapor to the mouth. Behaviorally, nicotine inhalers are the closes t thing to smoking a cigarette, which some smokers find helpful. Learning about Healthy Living – Revised 2012 Page | 40

47 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches  The most common side effects, especially when first using the inhaler, include: coughing, throat irritation and upset stomach. Bupropion: Bupropion SR (generic name) is EXACTLY th e SAME medication as Wellbutrin SR or Zyban. Bupropion SR (Zyban or Wellbutrin) is also an approved prescription treatment for major depression. Psychiatrists and other ph ysicians have prescribed it for years to treat depression and it is a safe and effective medication. Bupropion SR was later reducing their craving for cigarettes and discovered to help people quit smoking by nicotine withdrawal.  Bupropion can be used alone or together with nicotine replacement. This medication should not be taken if  you have a history of seizures, bulimia (binge and purge eating disorder), or head trauma. It should not be taken with alcohol or other street drugs, since it can cause seizures in combination with these substances. If you have bipolar disorder or a history of manic episodes you may still be able to take Bupropion SR b ut you should first di scuss it with your doctor. Bupropion SR can only be taken with a doct  or’s prescription and supervision. It is usually started about two weeks before the Quit date. Most people take a dose of 300mg per day of Bupropion SR.   As with all medications, there is always the possibility of having some side effects. If you have any side effects, you shou ld inform your doctor or clinician immediately.  The most common side effects of Bupropio n SR are dry mouth, insomnia (trouble sleeping) and headache. Many people do not experience side effects from taking Bupropion SR. It is recommended that you continue taking bupropion SR for at least 12 weeks (3  o take bupropion SR for this length of months) after you quit smoking. People wh time or longer experience less weight ga in than people who take no medication (or a placebo or sugar pill) to quit smoking. Bupropion SR is not addicting or habit form  ing. Many people can stop taking it easily without a problem, however you shou ld first discuss this with your doctor.  Bupropion SR works to help all kinds of people quit smoking. It helps people who have a history of depression and thos e who do not. Sometimes it even helps in the past. This means that a re-trial people who have not been able to quit on it of Bupropion SR might be helpful to so me people who have tried it before. Page | 41 Learning about Healthy Living – Revised 2012

48 SECTION 4: Group I - Facilitators Guide 2012 Go als, Objectives & Suggested Approaches Varenicline (Chantix) Varenicline is a smoking treatment that does not contain nicotine and some studies have shown it is the most effective treatment current ly available to help people stop smoking. cotine which helps take it is still getting ni Varenicline tricks your brain into thinking the pleasure associated with smoking. away nicotine withdrawal. It also blocks Varenicline is not used in combination with nicotine medications. Varenicline can only the Quit date. be taken with a doctor’s prescription. It is usually started one week before It is recommended that you continue taking varenicline for 3-6 months after you quit smoking. This medication should not be taken if you ha ve a serious kidney di sease. Some people is will be less if you take the medication get nausea when they take varenicline but th with food. Learning about Healthy Living – Revised 2012 Page | 42

49 SECTION 5: Group I - Handouts 2012 Healthy Living Education Group Table of Contents: Group 1 Learning about Healthy Living Education Group CHAPTER CHAPTER TITLE PAGE Introduction Welcome to the Healthy Living Group 45 1 Starting on the Road to Healthy Living 46 2 50 Why Is Smoking Dangerous? 3 What’s In Cigarette Smoke? 52 4 Why Do So Many Consumers with Mental Illness 54 Smoke? 5 What Is Carbon Monoxide? 56 6 How Much Does Smoking Cost? 58 How Does Tobacco Advertising Affect Me? 62 7 8 66 What Is Second Hand Smoke? 9 How Are My Medications Affected by Smoking? 68 10 Why Are Cigarettes Addictive? 70 What Are My Smoking Patterns? 72 11 How Can I Better Manage Stress? 73 12 13 How Much Physical Activity Do I Need? 77 14 How Can I Make Healthier Food Choices? 81 15 87 Why Should I Quit Smoking? 16 What If I’m Not Ready to Quit? 91 17 Is it Really Possible For Me to Quit Smoking? 93 18 What Happens When I Quit Smoking Without Help? 97 19 How Do Medications Help Me Quit Smoking? 101 Which Medications Should I Use? 20 102 Learning about Healthy Living – Revised 2012 Page | 43

50 SECTION 5: Group I - Handouts 2012 Healthy Living Education Group Learning about Healthy Living – Revised 2012 Page | 44

51 SECTION 5: Group I - Handouts 2012 uction Introd Welcome to the Healthy Living Group This group has been especially designed for you to look at ways you could improve your life by learning more about healthy living. We will talk about general topics such as proper nutrition, exercise and ways to deal with stress, as well as look at how your current use of tobacco affects you and the people around you. This group will give you an opportunity to discuss your feelings about why you smoke and whether or not you may want to try to quit. It is very common for people to have mixed feelings about their smoking. Our goal is to provide you with the facts about what is in the cigarettes that you smoke and how it may impact your health. We know that the tobacco industry tries to mislead you by the billions of dollars they spend in advertising. You have a right to make educated decisions about how you choose to live your life and learn new things you may want to do to improve it. Participating in this group will give you an opportunity to share your thoughts or questions with other group members and learn from each other. We encourage you to attend each group! Page | 45 Learning about Healthy Living – Revised 2012

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53 SECTION 5: Group I - Handouts 2012 C hapter 1 Starting on the Road to Healthy Living Healthy living makes a positive impact on many areas of our lives. Healthy living is not only about feeling good physically. Physical well-being improves mood, decreases risk for chronic illnesses, such as diabetes and hypertension, and improves your quality of life, which in turn can increase satisfaction with our life and relationships. Like many Americans, people diagnosed with psychiatric illnesses may practice unhealthy lifestyle habits such as lack of regular physical activity, poor nutrition and over eating, smoking and other drug abuse, not visiting health care professionals regularly, and not getting enough sleep. These unhealthy behaviors may increase the risk for disability and illnesses such as obesity, heart disease, diabetes, and sometimes even cause premature death. The good news is people can choose to live a healthier life! Developing a healthy lifestyle does not have to be overwhelming. It can be a step-by-step process making small changes towards the bigger goal of “Complete Wellness.” It is important to recognize where you are on the “Road to Healthy Living,” and to set goals that are important to you as you make this journey. You are now taking your first step. Congratulations! Page | 46 Learning about Healthy Living – Revised 2012

54 SECTION 5: Group I - Handouts 2012 C hapter 1 Steps Towards 6 Healthier Living Remember, your health is a very important part of your 1. recovery plan. The recovery process should reflect all aspects Continue of your life including your physical well-being. with your mental health and recovery plan. Try a piece of fruit 2. Make healthy food choices every day. for dessert instead of a cookie or ice cream, or try drinking water instead of soda. can Daily physical activity of 30 minutes or more 3. improve your overall health and reduce the risk of disease (you 10 minutes 3 times a day). can even break that up into . Find a balance between relaxation and stress 4. Unfortunately, during times of stress some of us turn to less helpful coping strategies like smoking or eating too much. 5. Get regular Make sure you have a primary care practitioner. Schedule yearly physical health check-ups and exams. vision and dental exams and other screening tests as needed. Part of the recovery Take control of addictive behaviors. 6. process is attending to all issues that impact our health and wellness and make a difference in the quality of our lives. Addressing addictive behaviors including alcohol and other drugs including tobacco and caffeine are important. Learning about Healthy Living – Revised 2012 Page | 47

55 SECTION 5: Group I - Handouts 2012 C hapter 1 do I smoke: _______ How many cigarettes per day are you in learning more about to How interested bacco? Please check one box. 1 2 3 4 5 6 7 8 9 10 Not at all interested e Interests Extremely Interested Averag To learn more about your overall health, you may wish to fill out On the Path to Healthy Living Questionnaire (Section the 8 Appendix/Forms) located in the back of this book. It can help you see how you are doing with all six steps towards healthier living. It may also help you start a conversation with your doctor, or other people who support you, on your journey towards “Complete Wellness.” For information about determining if you are at a healthy weight look at Body Mass Index (BMI) for Adults information found in Section 8. It can help you learn more about weight compared to height, and if you are at an increased risk of developing weight related health concerns such as diabetes or hypertension. Later in this book, we will give you information about what you can do to improve healthy eating, physical activity patterns, and stress, to reduce your risk of getting these problems. Learning about Healthy Living – Revised 2012 Page | 48

56 SECTION 5: Group I - Handouts 2012 hapter 1 C The major focus of this book is about one of the most harmful health choices that some people make: tobacco use. You will learn how smoking affects your health so that you can make the best possible choices about your life and your health! . . . Get ready to take your next step on the road to Healthy Living. Turn the page . . . Page | 49 Learning about Healthy Living – Revised 2012

57 SECTION 5: Group I - Handouts 2012 Cha p ter 2 Why is Smoking Dangerous? Here are some facts to consider about tobacco and smoking.  For every 5 deaths per year in this country, at least 1 is due to smoking. Smoking causes 9 out of 10 (90%) cases of lung cancer   Smoking causes nearly all cases of chronic obstructive pulmonary disease (COPD, chronic asthma/bronchitis or emphysema).  Smokers are twice as likely to die from stroke or heart attack, compared to non-smokers  Smokers miss more days of work than non-smokers  Smoking is also a risk factor for cancer of the mouth, throat, stomach, pancreas, kidney, bladder, cervix, liver, esophagus, uterus, colon, and leukemia Tobacco addiction is the most common addiction in the United States. Learning about Healthy Living – Revised 2012 Page | 50

58 SECTION 5: Group I - Handouts 2012 Cha p ter 2 now that you believe are Do you have any symptoms caused by your smoking? ____ No Yes (check all that apply) ____  Cough  Trouble breathing  Bad breath  Nicotine stains on my skin  Gum disease and dental problems  Wrinkles _____________________  Other ___________  Other ___________ _____________________ now that you believe is Do you have a disease or illness caused by your smoking? ____No ____Yes (check all that apply)  Chronic bronchitis/ Asthma/ COPD/ Emphysema  Heart attack or other heart disease  Stroke  Other circulation problems (cramping in legs)  Lung cancer  Other cancer  Early menopause  Peptic Ulcer  Other ___________ _____________________  Other ___________ _____________________ Do you worry about getting a smoking-caused disease or ____Yes illness? ____No Learning about Healthy Living – Revised 2012 Page | 51

59 SECTION 5: Group I - Handouts 2012 Chapter 3 What’s in cigarette smoke? Many things are found in a cigarette. When cigarettes are made, flavors, additives and other chemicals are added to tobacco to enhance the smoking experience. Most of the harmful chemicals in cigarettes are released as gases when cigarettes are burned.  Over 7,000 chemicals are produced by cigarette smoke!  Nicotine, is only one of the 7,000 chemicals found in the smoke of a tobacco product. (cigarettes, cigars, pipes), Nicotine is a drug found naturally in tobacco. Nicotine is highly addictive. When you smoke, nicotine goes deep into the lungs where it is quickly picked up in the blood and taken throughout the body. Nicotine affects many parts of the body including your heart, blood vessels, your metabolism and your brain. The nicotine used in medications is safe because it is monitored by your doctor. bstance that is the main cause  Cigarette Tar is a sticky brown su of lung and throat cancer in smokers. There are 66 KNOWN cancer-causing chemicals and  400 other known harmful chemicals that make smoke DEADLY! Some examples are: ▪ Lead is a harmful metal, capable of causing serious damage to the brain, ki dneys, nervous system and red blood cells. Nickel causes increased susceptibility to lung infections. ▪ ▪ Formaldehyde causes respiratory and gastro-intestinal problems. found in cigarette smoke. 7,000 different chemicals are Learning about Healthy Living – Revised 2012 Page | 52

60 SECTION 5: Group I - Handouts 2012 Chapter 3 When you smoke you inhale up to 7000 chemicals including these poisons that are found in the following products: Acetone: Paint Stripper and Nail Polish Remover Ammonia: Floor Cleaner Arsenic: Ant Poison Benzene*: Industrial Solvent / Fuel, Dyes, Synthetic Rubbers Butane: Lighter Fluid, Key Component of Gasoline Cadmium*: Used in Car Batteries Carbon Monoxide: Poisonous gas in car exhaust DDT: Insecticides Formaldehyde*: Embalmers use it to preserve dead bodies Hydrogen Cyanide: Poison used in gas chambers Rocket Fuel Methanol: Disinfectants Phenol: Naphthalene: Mothballs Industrial solvent Toluene: *Other known cancer causing substances : Naphthylamine, Pyrene, Benzopyrene Vin -210 m Poloiu , Dibenzacridine Urethane , , y l Chloride , Toluidine Name 3 chemicals that you were surprised to find are in cigarette smoke: ___________ 3._____________ 1. _____________ 2.___ Try to find two common household products Practice Assignment: that contain some of the chemicals listed in cigarettes. Learning about Healthy Living – Revised 2012 Page | 53

61 SECTION 5: Group I - Handouts 2012 Chapter 4 Why do so many consumers with mental illness smoke? There is no easy answer as to why so many people living with mental illness smoke. Smoking is a complex problem made up of biological, psychological and social/environmental factors. BIOLOGICAL FACTORS (Physical/ Brain Functions) People living with a mental illness may be at increased risk for physical addiction to smoking. Nicotine may help improve mood, or mental functions like attention, memory or learning, in some people diagnosed with mental illness. PSYCHOLOGICAL FACTORS (Thinking/ Feeling) People diagnosed with a mental illness may not feel confident that they can quit. People diagnosed with a mental illness may rely on smoking to help them cope with stress. SOCIAL FACTORS (People/ Places/ Things Around You) Smoking is common in and around mental health hospitals, treatment centers and group homes. People with a mental illness may feel like it is easier to talk with others and be around others when they are smoking. Learning about Healthy Living – Revised 2012 Page | 54

62 SECTION 5: Group I - Handouts 2012 Chapter 4 Why do you believe so many people with mental illness smoke? ________________________________________________________________________________ ________________________________________________________________________________ What reason or factor do you feel made you want to smoke? ________________________________________________ ________________________________________________ ____________________________ ____________________ IMPORTANT POINTS TO REMEMBER Tobacco addiction is the most common substance abuse disorder for people with mental health problems. People diagnosed with a mental illness are three times more likely to be a smoker than people without a mental illness. Learning about Healthy Living – Revised 2012 Page | 55

63 SECTION 5: Group 1 – Handouts 2012 Chapter 5 What is Carbon Monoxide? One of the most deadly chemicals found in cigarette smoke is carbon monoxide (CO). d colorless gas. Burning cigars, Carbon monoxide is an odorless an cigarettes and pipes all produce carbon monoxide. Carbon monoxide is found in air pollution but the levels absorbed low compared to the amount in by the body from pollution are very tobacco smoke. Carbon monoxide takes the place of oxygen in your blood. The body ng that decreases the amount of needs oxygen to survive and anythi oxygen causes strain on the heart and body. Over time, the heart has to work harder to deliver oxygen. This puts for having heart attacks. smokers at greatly increased risk The Good News about Carbon Monoxide Although it is very deadly, carbon monoxide lasts only a short time in your body. Your body can eliminate carbon monoxide within two to three days AFTER you quit smoking. Your carbon monoxide level will go back down to the same level of somebody who never smoked – “0”. The effect of carbon monoxide is reversible and can get y if you stop smoking. better almost immediatel Learning about Healthy Living – Revised 2012 Page | 56

64 SECTION 5: Group 1 – Handouts 2012 Chapter 5 Carbon Monoxide Meter A carbon monoxide meter measures the amount of carbon monoxide in your body. My Carbon Monoxide Level is = _______________ 0 - 8 Normal or very low smoking 8 - 12 Concern 12 - 25 Warning 25 - 40 Danger Over 40 Severe Danger If I quit smoking, my Carbon Monoxide Level will go down to: Learning about Healthy Living – Revised 2012 Page | 57

65 SECTION 5: Group 1 – Handouts 2012 Chapter 6 How Much Does Smoking Cost? It is important for you to realize how much money you spend on tobacco.  Smoking cigarettes is very expensive.  It costs $7.00 or more to buy a pack of cigarettes today. The tobacco companies only spend only pennies (about 6  cents) to make a pack of cigarettes.  That means that the tobacco companies make several dollars profit on each pack of cigarettes that you buy and the government gets a few dollars!  The more you smoke...the more money the tobacco industry makes. Did you know that the Tobacco Companies make more than $32 billion dollars each year Important point to remember: 1 Pack of Cigarettes Costs Approx $7.00 Minus 6 Cents it Costs to Make -.06 BALANCE $6.94 This balance includes the profits made by the tobacco companies and taxes paid to the government. Learning about Healthy Living – Revised 2012 Page | 58

66 SECTION 5: Group 1 – Handouts 2012 Chapter 6 How much does smoking cost? Look at the chart below and estimate how much smoking cigarettes costs you every day, week, month and year. Sometimes we don’t realize how much we are spending on things until we stop to total the cost. The following chart is based on a pack of cigarettes costing about $7.00: 2 3 Column 1 5 6 4 Approximate Number Average Cost Average Average Average Average Cost Per in 10 Years of Cigarettes that I Cost Per Cost Per Cost Per Month Year Smoke Each Day Week Day $98.00 $11,760.00 ½ pack (10 cigs) $3.50 $24.50 $1,176.00 1 pack (20 cigs) $49.00 $196.00 $2,352.00 $23,520.00 $7.00 1 ½ packs (30 cigs) $10.50 $73.50 $294.00 $3,528.00 $35,280.00 2 packs (40 cigs) $14.00 $98.00 $392.00 $4,704.00 $47,040.00 2 ½ packs (50 cigs) $17.50 $122.50 $490.00 $5,880.00 $58,800.00 3 packs (60 cigs) $72,240.00 $21.00 $150.50 $602.00 $7,224.00 (This chart is based on a pack of cigarettes costing about $7.00 and does not include inflation.) In Column 1, select: How much do you smoke per day? _____ pack Follow the row across to figure out: Column 2 Average Cost per Day $___________ Column 3 Average Cost per Week $___________ Column 4 Average Cost per Month $___________ Column 5 Average Cost per Year $___________ $___________ Column 6 Average Cost in 10 Years If YOU Quit Smoking...YOU WILL SAVE A LOT OF MONEY! Learning about Healthy Living – Revised 2012 Page | 59

67 SECTION 5: Group 1 – Handouts 2012 Chapter 6 If you are on a Fixed Income, it can be hard to manage a monthly budget Write Your Monthly Income Here $ / month SUBTRACT BILLS - Rent or Mortgage - - Utilities (heat, electric bills) Telephone or cable TV - Food - Clothes or Entertainment - Other: - AMOUNT LEFT $ Can you really afford to keep smoking? It is important for you to think about what you can buy or do for yourself with this money. It is a special way to congratulate yo u for being able to quit smoking. Thinking of something special that you may want can help to stick to your goal to quit. Learning about Healthy Living – Revised 2012 Page | 60

68 SECTION 5: Group 1 – Handouts 2012 Chapter 6 What Can You Do With the Money That You Will Save? What things do you need or want that you could buy or do for yourself with the extra money you will have from quitting smoking? □ Shirt □ Music CDs or MP3 player □ □ Go on a trip Pants □ Socks □ Take guitar lessons □ Shoes □ Join a gym □ Coat or Jacket □ Go out to dinner Have a party for my friends □ □ Jewelry □ □ Celebrate my birthday Television □ Cell Phone □ Take significant other on a date □ Microwave Oven □ Go to the movies □ Coffee Maker □ Other ______________ □ Computer □ Other_______________ What are the three most important things that you would want to have or something you would like to do? Approximate Cost 1. _____________________________ _____________ 2. _____________________________ _____________ 3. _____________________________ _____________ Learning about Healthy Living – Revised 2012 Page | 61

69 SECTION 5: Group 1 – Handouts 2012 Chapter 7 How does tobacco advertising affect me? The tobacco companies use a lot of the money they make to  pay for expensive advertising in magazines.  Tobacco companies distribute coupons through direct mail, newspapers or other advertising, and take-home items in retail stores. These ads focus on getting more people hooked on smoking  every day. Did you know that ½ of all cigarettes bought in the USA are purchased by people with mental health problems? Did you know that the tobacco ad verting agencies try to trick people into thinking that smoking is a lot of fun or that it will make them a happier person. Sometimes ads even show people falling in love or making a lot of friends. SMOKING CIGARETTES WILL NOT DO THAT! IMPORTANT POINTS TO REMEMBER THE TOBACCO COMPANIES ARE TRYING TO TRICK YOU!  Smoking WILL NOT make you a happier person.  Smoking WILL NOT help you to make friends or fall in love.  Light, extra light, ultra light, special mild cigarettes give you the same dangerous chemicals as regular brands. Every cigarette puts dangerous tar into the lungs of smokers. Learning about Healthy Living – Revised 2012 Page | 62

70 SECTION 5: Group 1 – Handouts 2012 Chapter 7 What about smoking ‘light’ cigarettes? The word light does not refer to how much a cigarette weighs. All cigarettes weigh about the same. Cigarette companies use words like ‘light’, ‘extra light’, ‘ultra light’, ‘mild’ and ‘special mild’ on cigarette packs. They made these cigarettes so that consumers would assume that ‘light’ cigarettes are not as harmful. These cigarettes were tested on machines and are suppose to contain less tar and nicotine than regular bran ds. However, people who smoke light cigarettes usually breathe more deeply, smoke more often and will cover up the tiny ventilation holes in the filter with their fingers. What really happens...the smoker ends up with the same amounts of dangerous chemicals from ‘light’ cigarettes as they would from a ‘regular’ brand. Learning about Healthy Living – Revised 2012 Page | 63

71 SECTION 5: Group 1 – Handouts 2012 Chapter 7 Advertising Exercise 1. Look through a magazine and find an ad about cigarettes. 2. How do the people look in the ad?  Happy Having Fun  Healthy   Sad Angry   Bored 3. Where are they? What are they doing? 4. 5. What is the tobacco advertising company trying to make you believe about smoking cigarettes? 6. Do you think that this ad is tr ying to trick you into making smoking seem better that it really is? _____ YES _____ NO Learning about Healthy Living – Revised 2012 Page | 64

72 SECTION 5: Group 1 – Handouts 2012 Chapter 7 Design an Ad Activity In the space below, design an ad that represents the truth about smoking. Learning about Healthy Living – Revised 2012 Page | 65

73 SECTION 5: Group I – Handouts 2012 C ter 8 p ha What is Second-Hand Smoke? Cigarette smoke is not only dangerous to you but also to the health of those around you. This is called “second- hand” smoke. Research has shown that second-hand smoke causes thousands of deaths each year in non-smokers. Secondhand smoke can also cause eye irritation, headaches, nausea, and dizziness. The lungs of young children are also affected by secondhand smoke. Babies and children living in a home where there is smoking tend to have more ear infections, colds, bronchitis, and other respiratory problems than children from nonsmoking families. Smoking while pregnant is associated with low birth weight infants and Sudden Infant Death Syndrome. (SIDS). There was a new warning from the U.S. Centers for Disease Control (CDC) in April 2004, which stated that people at risk for heart disease should stay away from tobacco smoke. Secondhand smoke can significantly increase the risk of a heart attack in persons with Coronary Artery Disease. Thirty minutes’ exposure can have a serious and lethal effect. IMPORTANT POINT TO REMEMBER When you smoke, it is dangerous to YOU and to THOSE AROUND YOU! Learning about Healthy Living – Revised 2012 Page | 66

74 SECTION 5: Group I – Handouts 2012 C ha p ter 8 W ho used to smoke around you? W hat was that like for you? W ho else around you is affected by your smoking? Learning about Healthy Living – Revised 2012 Page | 67

75 SECTION 5: Group I – Handouts 2012 Chapter 9 How are my medications affected by smoking? Many commonly used medications interact with chemicals in tobacco smoke. This results in a lowering of blood levels of these medications. Stopping smoking also interacts with medications but in the opposite way- it raises medication levels. That is why it is important for your doctor to know if you smoke and when you decide to quit smoking. The liver is an important organ for purifying the body.  By working hard to remove harmful chemicals and toxins from the body, the liver can keep the body in a normal balance.  Even medications that we use to treat disease are removed from the body in this way. Tars in cigarette smoke “turn on” a part of the liver system. This means that in a smoker, this enzyme works faster and  better than usual. In smokers, some medications are taken out of the body faster  than normal.  Smokers may need to be on higher medication doses, in order to correct this problem and for those medications to work.  This is not usually a good thing and can lead to more medication side effects.  R IMPORTANT POINT TO REMEMBE The effect of tars on the liver could result in: 1. Higher medication doses for a smoker Medications not working as well in a smoker 2. 3. More side effects from medication in a smoker Learning about Healthy Living – Revised 2012 Page | 68

76 SECTION 5: Group I – Handouts 2012 Chapter 9 These are the medications that are affected by smoking. Check ( √ ) the box below if you are currently taki ng any of these medications. ) Check Here ( √ Generic Name Trade Name Elavil A mitriptyline A nafranil Clomipramine A ventyl/ Pamelor Nortriptyline Tofranil Imipramine Luvox Fluvoxamine Thorazine Chlorpromazine Prolixin Fluphenazine Haldol Haloperidol Clozaril Clozapine Zyprexa Olanzapine Tylenol A cetaminophen Inderal Propranolol Slo-Bid Slo-Phyllin, Theo- Theophylline 24, Theo-Dur, Theobid, Theovent Coffee/Tea Caffeine What other medications are you taking? __________________________________________ Talk to your doctor  About your current medications and the effect of smoking. Tell your doctor  If you are thinking about quitting smoking since it can have an impact on your medications. Learning about Healthy Living – Revised 2012 Page | 69

77 SECTION 5: Group I – Handouts 2012 ter 10 p Cha Why are cigarettes addictive? Most people who smoke are addicted to the nicotine chemical that is contained in cigarettes and other tobacco products. The tobacco companies want people to be dependent on cigarettes, because they want them to continue to smoke. Tobacco addiction is one of the most common addictions and substance abuse disorders in the United States. People can be addicted to other things such as, food, sex, caffeine, alcohol, illegal drugs, gambling, and even exercise. Whenever you do something TOO MUCH, it can be bad for you! But some addictions, such as smoking or taki ng illegal drugs are dangerous any time you do it. What is tobacco addiction? Think about when you first began to sm oke. Did you first try it when you were very young or as a teenager? Were you with friends? Then after you smoked for a while, you started wanting to smoke more. Well, being addicted means that whenever you smoke, you want to smoke more. And if you don’t smoke, your body begins to crave (really want to have) another cigarette. What is tobacco withdrawal? When you don’t have a cigarette, you may begin to feel withdrawal symptoms. Many times, people will feel this way in the morning. That is because when they were sleeping they could not have a cigarette. Some withdrawal symptoms are: being i rritable, feeling anxious, feeling frustrated, being restless, feelin g depressed and feeling angry. IMPORTANT POINT TO REMEMBE R Being addicted means that even if you know something is really bad for you, you continue to do it. We all know how bad smoking is for our health, yet people continue to smoke. Learning about Healthy Living – Revised 2012 Page | 70

78 SECTION 5: Group I – Handouts 2012 ter 10 Cha p Are you addicted to tobacco? SELF QUIZ: How many years have you smoked? _____ years Do you smoke more now than you did when you first tried smoking cigarettes? _____ Yes _____ No garette as soon as you wa ke up in the morning? Do you want to have a ci _____ Yes _____ No How soon after you wake up do you smoke your first cigarette? __within 5 minutes __6-30 minutes __31-60 minutes __ after 60 minutes When you are not having a cigare tte, do you think about smoking? _____ Yes _____ No If you don’t have a cigarette, do you start to have withdrawal? _____ Yes _____ No Check any withdrawal symptoms you began to feel when you did not have a cigarette?  Anger  Impatient  Anxiety Insomnia (cannot sleep)   Crying  Irritable Depressed Mood   Nervous Difficulty Concentrating   Restless  Frustrated _____ No _____ Yes Do you think you are addicted to smoking? Learning about Healthy Living – Revised 2012 Page | 71

79 SECTION 5: Group I – Handouts 2012 Chapter 11 What are my smoking patterns? How can I change my smoking patterns? You are now more aware of your usual smoking patterns. By thinking about these, you can begin to make choices about when and why you smoke. Although you may not be ready to quit right now, you may want to think about making some changes in your current smoking patterns. These may make the choice to quit smoking in the future an easier one. Example: Instead of smoking with your morning coffee You can make a change by:  Delay having a cigarette until 30 minutes after your coffee Plan to drink morning coffee in a different room or non-  smoking area List 1 smoking pattern that would be hard for you to give up. How could you try to change this smoking pattern? ________________________________________________ ________________________________________________ ____________________ ____________________________ Learning about Healthy Living – Revised 2012 Page | 72

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81 SECTION 5: Group I – Handouts 2012 Cha p ter 12 How can I better manage stress? Are you feeling stressed out? First of all, it is important to know that STRESS is a part of life! How YOU CHOOSE to deal with your stress is what we want to think about. Some people yell and scream when they are stressed out. Others may hide in their rooms and cry. Some people will eat, smoke or drink when they are under stress. However you choose to deal with your stress... BE SURE THAT WHAT YOU DO IS REALLY HEALTHY AND HELPFUL! A good way to cope is to learn skills to help you relax. DEEP BREATHING We will teach you the skill of deep breathing to help you relax. Many times, people take short breaths when they are under stress. This does not give your body the proper amount of oxygen it needs. Remember that smoking also takes away the good oxygen that it needs. Learning deep breathing exercises makes you feel relaxed by breathing slowly and giving your body more oxygen. This skill takes 3 to 5 minutes to do. It involves both your chest and stomach muscles. While doing this exerci se, try to focus on the sound and feel of your breathing. Learning about Healthy Living – Revised 2012 Page | 73

82 SECTION 5: Group I – Handouts 2012 ter 12 p Cha EXERCISE: DEEP BREATHING Practice Deep Breathing for the next 3 to 5 minutes. 1. Sit in a chair - arms at sides, feet uncrossed. 2. Note any tension or tightness in your muscles. 3. Put one hand on your chest and your other hand on your stomach. Take a slow, deep breath through your nose. As your lungs 4. fill your stomach should raise first and the chest next. Hold the air in for three seconds. 5. 6. Blow the air out through your mouth, making a whooshing sound. 7. Keep taking long, slow deep breaths in through your nose and letting long slow breaths out through your mouth. 8. Focus on the sound of your breath. Do this for 3 to 5 minutes. How do you feel after practicing the Deep Breathing exercise? Was it hard for you to do the exercise? Sometimes people who smoke have a hard time doing this exercise and will begin to cough. You will find that if you quit smoking, it will be easier to do as well as practicing this exercise every day. Learning about Healthy Living – Revised 2012 Page | 74

83 SECTION 5: Group I – Handouts 2012 ter 12 Cha p uld actually cause you to be Did you know that cigarettes co tense and ADD to the STRESS in your life? Smokers believe that when they have a cigarette, it eases the feelings of anxiety or restlessness that they are feeling. As we learned earlier, these same feelings of anxiety and restlessness are caused from withdrawal (or not having a cigarette because the body needs one). Smokers often mention stress as a reason keeping them from quitting. Smokers have learned to use tobacco to help cope with stress. Remember... Smoking and stress do not have to go hand in hand. There are other healthy things you can do to make yourself feel better! Cigarettes will not take away your problems. Smoking will usually only add to the problems you already  have. When you quit, you have to learn new ways of handling stress.  Physical activity and healthy eating can help to reduce stress.  Making sure that you have time to do the things you like to do is very important.  Sometimes writing down your feelings and frustrations will help to relieve stress.  Making a “to do” list each day can also be very helpful. As you complete them, check them off and you will see everything that you accomplished. This technique helps you to remember and will also take away the stress of worrying to remember to do them. Learning about Healthy Living – Revised 2012 Page | 75

84 SECTION 5: Group I – Handouts 2012 a p ter 12 Ch For some people, being outside in nature is helpful. Sitting at a  ry relaxing. Sometimes just park or on a beach can be ve closing your eyes and imagining that you are at your favorite place can be relaxing. Spiritual practices such as prayer and meditation can help you  to have a more peaceful life.  Twelve step recovery programs teach a very valuable tool: “Take One Day at a Time” . s is also very important.  Learning relaxation exercise  Deep Breathing  Progressive Muscle Relaxation day can be a helpful tool. Making a “TO DO” list each As you complete each item, you will be able to see all that you accomplished. Writing things down the night before helps you to get them off of your mind so that you do not have to worry about it during the night. TO DO LIST Date ________________ Learning about Healthy Living – Revised 2012 Page | 76

85 SECTION 5: Group I – Handouts 2012 Cha ter 13 p How much physical activity do I need? What is PHYSICAL ACTIVITY? The 2005 USDA Dietary Guidelin es tell us that physical activity means movement of the body that uses energy. Walking, gardening, climbing the stairs, playing soccer, or dancing are all good exam ples of being physically active. Physical activity can help you ment ally as well as physically! Do you know why? Your muscles, your heart, and other parts of your body grow stronger and more efficient when they are called on regularly when you are physically active. Regular exercise can help prevent heart disease, normalize blood pressure, regulate blood sugar, prevent bone loss, and promote weight loss. It can also help people manage their stress, f eel better about themselves, and provide pleasure and enjoyment! How Much Physical Activity Do I Need? The USDA Dietary Guidelines for Americans say: 30 minutes most days of the week for health benefits 60 minutes to prevent weight gain 60—90 minutes to maintain weight loss Learning about Healthy Living – Revised 2012 Page | 77

86 SECTION 5: Group I – Handouts 2012 p Ch ter 13 a To maintain a healthy weight, bala nce your calories with physical activity. Here are some suggestions for ac tivities to get you moving:  Get active for 10 minutes 3 times a day everyday  Get off the bus one or two stops early and walk the rest of the way  March in place during TV commercials  Park your car a block or two away and walk  Use the stairs instead of the elevator Rake the leaves   Take a walk after dinner instead of watching TV  Moving any part of your body—even for a short time— can make you healthier  Walk the dog Take 2-3 minute walking breaks throughout the day  Put away the TV remote control—get up to change the  channel  Walk while you talk on a cordless phone  Plan your errands around town so they are walking distance from each other, i.e. post office, library, cleaners, pharmacy  Walk with a friend at lunchtime for 10 minutes  Walk to the store and home instead of driving  Dance to some of your favorite songs or radio station Garden in the yard or clean a room  Learning about Healthy Living – Revised 2012 Page | 78

87 SECTION 5: Group I – Handouts 2012 p ter 13 Cha Regular physical activity means doing something active most if not all days of the week! If you are over 40 or have health problems check with your doctor before starting an exercise program. Experts advise that people with chronic diseases, such as a heart condition, arthritis, diabetes, or high blood pressure, should talk to their doctor about what types and amounts of physical activity are appropriate. ) http://www.cdc.gov (Source: Learning about Healthy Living – Revised 2012 Page | 79

88 SECTION 5: Group I – Handouts 2012 ter 13 p Cha Think about your physical activity level. Generally, how much physical activity do you get every day? Minutes per day = ________________ Why is being physically ac tive beneficial to you? 1. ____________________ ____________ _____________ 2. ____________________ ____________ _____________ 3.____________________ ____________ _____________ List several things you do now for physical activity: _____________ 1. ____________________ ____________ 2. ____________________ _____________ ____________ 3.____________________ ____________ _____________ List one or two new things you are willing to try in the next week that will add movement into your life: 1. ____________________ ____________ _____________ 2. ____________________ ____________ _____________ 3.____________________ ____________ _____________ Learning about Healthy Living – Revised 2012 Page | 80

89 SECTION 5: Group I – Handouts 2012 ter 14 Cha p How Can I Make Healthier Food Choices The 2005 Dietary Guidelines for Americans are the newest science-based advice from the United States Department of Agriculture. The Dietary Guidelines will help Americans make smart choices about food and physical activity, so they can have healthier lives. What do the experts say? We should make smart choices from every food group. The best way to give your body the balanced nutrition it needs is by eating a variety of nutrient-packed foods every day. But, be sure to stay within your daily calorie needs. A healthy eating plan is one that: Emphasizes fruits, vegetables, whole grains, and fat-free or  low-fat milk and milk products.  Includes lean meats, poultry, fish, beans, eggs, and nuts.  Is low in saturated fats, trans fats, cholesterol, salt (sodium), and added sugars.  Mixes up your choices within each food group. The information below is based upon a 2,000 calorie diet. Different people have different calorie needs. Servings will vary based upon to see how your diet compares to your calorie need. Turn the page what the experts recommend. Learning about Healthy Living – Revised 2012 Page | 81

90 SECTION 5: Group I – Handouts 2012 ter 14 p Cha Focus on fruits Eat a variety of fruits—whether fresh, frozen, canned, or dried— rather than fruit juice for most of your fruit choices. For a 2,000- calorie diet, you will need 2 cups of fruit each day (for example, 1 small banana, 1 large orange, and 1/4 cup of dried apricots or peaches). How many servings of fruit do I usually eat each day? ________ Vary your veggies Eat more dark green veggies, such as broccoli, kale, and other dark leafy greens; orange veggies, such as carrots, sweet potatoes, pumpkin, and winter squash; and beans and peas, such as pinto beans, kidney beans, black beans, garbanzo beans, split peas, and lentils. What vegetable am I willing to eat more of?_________________ Get your calcium-rich foods Get 3 cups of low-fat or fat-free milk—or an equivalent amount of e (1½ ounces of cheese equals 1 low-fat yogurt and/or low-fat chees cup of milk)—every day. For kids aged 2 to 8, its 2 cups of milk. If you Learning about Healthy Living – Revised 2012 Page | 82

91 SECTION 5: Group I – Handouts 2012 ter 14 Cha p don't or can't consume milk, choose lactose-free milk products and/or calcium-fortified foods and beverages. What type of milk do I drink: __ whole milk __ 2% __ 1% __ skim Do I get enough calcium-rich foods? _____ Yes _____ No Make half your grains whole Eat at least 3 ounces of whole-grain cereals, breads, crackers, rice, or pasta every day, with the rest of the recommended grains coming from enriched or whole-grain products. One ounce is about 1 slice of bread, 1 cup of breakfast cereal, or ½ cup of cooked rice or pasta. Look to see that grains such as wheat, rice, oats, or corn are referred to as "whole" in the list of ingredients. Do I check to see if the grains I am eating are “whole-grains”? ____Yes ____No Go lean with protein Choose lean meats and poultry. Bake it, broil it, or grill it. And vary your protein choices—with more fish, beans, peas, nuts, and seeds. Do I trim the fat from chicken or meat before I cook or eat it? ____Yes ____No Do I remove the skin from chicken before I eat it? ____Yes____No Learning about Healthy Living – Revised 2012 Page | 83

92 SECTION 5: Group I – Handouts 2012 ter 14 Cha p Know the limits on fats, salt, and sugars Read the Nutrition Facts label on foods. Look for foods low in saturated fats and trans fats. Choose and prepare foods and beverages with little salt (sodium) and/or added sugars (caloric sweeteners). Do I read the Nutrition Facts Label on Foods? ____ Yes ___ No How many regular sodas do I drink per day? ___________ Did you know that water has 0 calories? ____ Yes ___ No On a scale of 1 (= very poor) to 10 = (excellent), rate how healthy your diet is? _____ List one thing that you are wi lling to do to improve your eating habits during the next week: _______________________ _______________________ Source: http://www.health.gov/dietaryguidelines/dga2005/document/html /brochure.htm#b1 Learning about Healthy Living – Revised 2012 Page | 84

93 SECTION 5: Group I – Handouts 2012 ter 14 p Cha Simple Things You Can Do to Maintain a Healthy Body Weight People sometimes worry about gaining weight when they quit smoking. Below is a list of things you can do to prevent weight gain. Check off all the things on the list below that you currently do:  Choose water instead of soda Choose fresh fruit instead of fruit juice (which is frequently  loaded with sugar)  Choose skim or low-fat milk instead of whole milk  Check serving size and calories. Look at the serving size on the nutrition fact label and know how many servings you are actually consuming. If you double the servings, you double the calories!  Make your calories count. Look at the calories on the label and compare them with what nutrients you are also getting to decide whether the food is worth eating. When one serving of a single food item is over 400 calories per serving, it is high in calories  Don’t sugarcoat it. Since sugars are loaded with calories and few, if any nutrients, look for foods and beverages low in added sugars. Read the ingredient list and make sure added sugars are not one of the first few ingredients. Some names for added sugars include sucrose, glucose, high fructose corn syrup, corn syrup, and fructose Try not to eat high-calorie “junk food” (such as potato chips,  cookies, candy, cake) Learning about Healthy Living – Revised 2012 Page | 85

94 SECTION 5: Group I – Handouts 2012 ter 14 Cha p  Snack on crunchy vegetables and fruit (such as carrots, celery, broccoli, cucumbers, red and green pepper slices, apples, oranges, strawberries, blueberries, and watermelon)  Stay away from fast food  Use sugar free gum and mints Write down one item from the list above that you are willing to 1. try this week: _______________________ _______________________ Remember to find your balance between food and physical activity. Increasing your physical activity can also help you find your way to a healthier you! Learning about Healthy Living – Revised 2012 Page | 86

95 SECTION 5: Group I – Handouts 2012 Chapter 15 Why should I quit smoking? Making the Decision Making the Decision t ui Q to NOT to Q t ui It is important to stop and ask yourself if YOU should consider quitting smoking. What would be the benefits of quitting or not quitting? We have already reviewed many of the harmful consequences and drawback s of smoking in earlier chapters. Some are listed below:  Health problems and diseases  Unpleasant problems including premature wrinkling of the skin, bad breath, bad smelling clothes, and yellow fingernails. Spending too much money on tobacco   Keeps me addicted Learning about Healthy Living – Revised 2012 Page | 87

96 SECTION 5: Group I – Handouts 2012 Chapter 15 There are many benefits to QUITTING SMOKING. Quitting smoking will also provide you with benefits that you will notice right away and some that take a few weeks to notice. Here are some good things about quitting smoking that can improve your life and daily lifestyle!  You will live longer. People who stop smoking before age 35 attributable to tobacco. Even avoid 90% of the health risks those who quit later in life can significantly reduce their risk of dying at a younger age Food will smell and taste better.   Ordinary activities will no longer leave you out of breath (climbing stairs, light housework.)  You will have more money  You will have fewer infections including the flu, cold, pneumonia and others.  Your skin will have a fresher look and may look younger. Learning about Healthy Living – Revised 2012 Page | 88

97 SECTION 5: Group I – Handouts 2012 Chapter 15 g Health Benefits of Quitting Smokin W ithin 20 minutes Blood pressure and pulse goes back to normal. fter 8 hours A blood drops to normal and the oxygen The carbon monoxide level in your level increases. 24 hours after quitting Your chance of a heart attack decreases. 2 weeks to 3 months after quitting Your circulation improves and your lung function increases up to 30%. From 1 to 9 months after quitting e easier and your overall You stop coughing and breath energy increases. Your cilia (tiny hair like structures that move mucus out of the lungs) regain the ability to handle mucus, clean the normal function in the lungs, increasing lungs, and reduce infection. 1 year after quitting The risk of coronary heart disease is cut in half. after quitting 5 years Your chances of lung cancer deat h and stroke are cut in half. 10 years after quitting The chances of lung cancer are equal to that of a non-smoker. The risk of cancer of the mouth, throat, esopha gus, bladder, kidney, and pancreas decrease. 15 years after quitting The risk of coronary heart disease is the same as a non-smoker. Learning about Healthy Living – Revised 2012 Page | 89

98 SECTION 5: Group I – Handouts 2012 Chapter 15 My Smoking Worksheet Pros of smoking : : Cons of smoking __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ : Cons of quitting smoking : Pros of quitting smoking __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Learning about Healthy Living – Revised 2012 Page | 90

99 SECTION 5: Group I – Handouts 2012 Chapter 16 Making the Decision to Quit Smoking What if I’m not ready to quit? Some smokers may still be feeling unsure about wanting to quit smoking.  It is very common to have mixed feelings about quitting. You may want to continue smoking or you may feel unready to  give it up. You might be thinking that quitting smoking is the right thing  to do, but feel scared about what it will be like.  Some of you may want to drop out of this program or group because of uneasy feelings or th e pressure to quit smoking. The feelings and situations described above are extremely common for smokers. It is likely that you have experienced one or more of them in the past. It is important to keep an open mind and explore this program. Even if you are unable to quit smoking at this time, learning more about your smoking is an important step toward a healthier lifestyle. You may choose to quit someday in the future. In addition, there are other steps you can take, while you are still smoking, that may be helpful to you. Learning about Healthy Living – Revised 2012 Page | 91

100 SECTION 5: Group I – Handouts 2012 Chapter 16 I’m not ready to quit smoking but I am ready to:  Come to group to talk about tobacco.  Read handouts  Talk to other people who used to smoke and learn about how they were able to quit  Count and keep track of how many cigarettes I smoke each day.  Recognize my smoking patterns. Delay smoking at certain times.   Make it more difficult for myself to smoke. I can move my cigarettes from their usual place. I can smoke with my other hand or do things that are not my usual smoking “habit”.  Try to reduce my carbon monoxide level.  Ask my family and friends how they feel about my smoking. Ask them if they would be able to help me when I try to quit.  Calculate how much I spend on tobacco each week, each month and each year. Think about the benefits of quitting smoking for me personally.   Change my smoking.  I’m beginning to think seriously about quitting smoking. Learning about Healthy Living – Revised 2012 Page | 92

101 SECTION 5: Group I – Handouts 2012 Chapter 17 Is it really possible for me to quit smoking? Many smokers use smoking to cope with the stresses and problems of everyday life. It’s hard for smokers to think of a life without smoking until  they learn new ways to manage stress and problems. Remember that different methods work for different people.  What may seem silly to others may be just what you need to quit - so don't be embarrassed to try something new.  Pick a coping strategy that make sense to you and then follow through by practicing it. It will get easier the more you practice.  When you are feeling stressed, use your new coping skills.  When you are ready to quit smoking, new coping skills will give you a much better chance of success. IMPORTANT POINT TO REMEMBE R Many smokers believe that stressful situations and problems in life is the reason that they smoke. It is important to recognize that when your body withdraws from nicotine, you may feel anxious and stressed and want to smoke. After a short time, these feelings will go away. Don’t confuse withdrawal symptoms, with stress. Learning about Healthy Living – Revised 2012 Page | 93

102 SECTION 5: Group I – Handouts 2012 Chapter 17 Better Coping Strategies THINGS YOU CAN DO INSTEAD OF SMOKING! 1. Take a long walk 2. Put together a list of household jobs to keep your hands busy. 3. Take a hot bath or shower 4. Smile a lot 5. Keep your hands busy by squeezing a stress ball or playing with “silly putty”. 6. Keep a sense of humor 7. Sing with a group or by yourself 8. Read a book 9. Jog or speed walk Do needlework 10. 11. Walk or window-shop at the mall 12. Get outside for some fresh air 13. Learn to accept things you cannot change 14. Help someone else 15. Write a letter to a friend 16. Go to a movie 17. Practice deep breathing. 18. Pray or go to church 19. Talk to a friend. 20. Listen to music that you like and helps you to relax or energizes you. 21. Take a short nap. 22. Think positive thoughts about yourself. Recognize and take pride in learning a new coping skill today. Learning about Healthy Living – Revised 2012 Page | 94

103 SECTION 5: Group I – Handouts 2012 Chapter 17 Think about a time when you used smoking to cope with the stresses and problems of everyday life. Are you satisfied with using smoking as a coping strategy? Learning about Healthy Living – Revised 2012 Page | 95

104 SECTION 5: Group I – Handouts 2012 Chapter 17 Why or why not? Is smoking the best coping strategy for you? Why or why not? Name 3 things you can do to manage your stress instead of smoke. 1. 2. 3. Learning about Healthy Living – Revised 2012 Page | 96

105 SECTION 5: Group I – Handouts 2012 pter 18 Cha What happens when I quit smoking without help? (cold turkey) Smokers that quit without tr eatment experience nicotine withdrawal. Remember: Nicotine is the substance found in cigarettes and other tobacco products that is addicting. This means that even though you want to stop smoking, your body is used to having nicotine put into it every day. Your body has become used to having nicotine and wants you to keep taking it even though you know that it is time to quit. This is called nicotine dependence addiction or Learning about Healthy Living – Revised 2012 Page | 97

106 SECTION 5: Group I – Handouts 2012 pter 18 Cha Nicotine Withdrawal When you don’t give your body nicotine, your body will signals. These are called react by sending you unpleasant withdrawal symptoms . The symptoms of nicotine withdrawal are listed below:  Irritable or angry mood Depressed or sad mood   Trouble sleeping  Feeling frustrated  Difficulty concentrating  Restlessness or “can’t get comfortable” feeling  Slower heart rate  Feeling hungry Learning about Healthy Living – Revised 2012 Page | 98

107 SECTION 5: Group I – Handouts 2012 Cha pter 18 IMPORTANT POINTS TO REMEMBER Smoking nicotine in cigarettes will immediately take away feel better. temporarily withdrawal symptoms and make you By giving you unpleasant symptoms, your body is tricking you into smoking and using nicotine over and over again forever. You can use a nicotine replacement medication to help break the addiction and not have to feel the unpleasant withdrawal symptoms. One time when I tried to quit smoking without treatment (“cold turkey”), I experienced these symptoms of nicotine withdrawal ____ No ____ Yes (check all that apply)  Irritable or angry mood  Depressed or sad mood  Trouble sleeping  Feeling frustrated  Difficulty concentrating  Restlessness or “can’t get comfortable” feeling  Slower heart rate  Feeling hungry Learning about Healthy Living – Revised 2012 Page | 99

108 SECTION 5: Group I – Handouts 2012 Cha pter 18 Having nicotine withdrawal symptoms in the past has caused me to smoke: ____ No ____ Yes The next time I try to quit smoking, I want to avoid having nicotine withdrawal symptoms ____ No ____ Yes Learning about Healthy Living – Revised 2012 Page | 100

109 SECTION 5: Group I – Handouts 2012 Cha pter 19 How do medications help me quit smoking? If you’re hooked on smoking or if you’ve tried quitting before and experienced nicotine withdrawal, think about using medications to quit. Medications to help you stop smoking are safe and effective. People that use medications to quit smoking have several advantages over people who don’t: They are twice as likely to be successful in quitting  smoking  They don’t experience uncomfortable nicotine withdrawal symptoms  They have less cravings or urges to smoke  They feel less depressed after quitting  They gain less weight while quitting smoking. Learning about Healthy Living – Revised 2012 Page | 101

110 SECTION 5: Group I – Handouts 2012 pter 19 Cha Different kinds of medications are available to help you stop smoking. They are all effective.   Some require a doctor’s prescription and others do not.  People choose them for different reasons Two are pill form and the other are all forms of nicotine, called  nicotine replacement.  Most medications to help you stop smoking cost less than the cost of a carton of cigarettes. Seven medications are available to help you stop smoking. (Check all the ones you have tried)  Nicotine gum  Nicotine patch  Nicotine lozenge  Nicotine inhaler  Nicotine nasal spray  Bupropion (pill)  Varenicline (pill) IMPORTANT POINT TO REMEMBER People who use medication to quit smoking are twice as likely to be successful as those who do not. Learning about Healthy Living – Revised 2012 Page | 102

111 SECTION 5: Group I – Handouts 2012 ter 20 Cha p Which medications should I use? You and your doctor will need to discuss which ll be best for you when you medication or medications wi try to stop smoking. In this chapter we will review the 7 types of medications available so you can decide which is best for you. Nicotine Patch, Nicotine Gum and Nicotine Lozenge Nicotine patch, nicotine gum and nicotine lozenge are all over-the- counter medications. Over-the-cou nter medications do not require a doctor’s prescription, although it is recommended that you still discuss the decision to use these medications with your doctor. Smokers who are pregnant or have heart disease should consult with their doctor before using nicotine medications. Nicotine patch, nicotine gum and nicotine lozenge cost about $35-55 for a 2-week supply of medication. Nicotine medication is started on the day that you try to stop smoking, also called the “Quit Date”. Never use nicotine medications if you plan to continue to smoke or use another tobacco product. The combined dose of nicotine could be dangerous to your health. Nicotine Patch Nicotine patches provide nicotine to your body through the skin. Nicotine patches give nicotine continuously through the day and are for 24 hours or removed at night easy to use. They can be worn when you sleep. Usually the patch is worn for about 12 weeks and the nicotine dose is lowered during this time. Several types and Learning about Healthy Living – Revised 2012 Page | 103

112 SECTION 5: Group I – Handouts 2012 ter 20 p Cha different strengths are available. Instructions are included in the package that describes how to use the product and include possible side effects. Nicotine Gum Nicotine gum provides nicotine to the body through the lining of the mouth. It works best if a piece of gum is chewed about every hour but more can be used when you have urges or cravings to smoke. Nicotine gum is a medication and is not used like regular chewing gum. It has a peppery taste and must be chewed slowly off and on for about 20 to 30 minutes. Don’t drink coffee, soda or other nutes before and during gum beverages for at least 15 mi use. Nicotine Lozenge Nicotine lozenge is a hard tablet that also provides nicotine to the body through the lining of the mouth. You suck on the lozenge until it dissolves and do not bite or chew it like a hard candy. The recommended dose for the lozenge: Week 1 through 6: one lozenge every 1-2 hours Weeks 7 through 9: one lozenge every 2-4 hours Weeks 10 through 12: one lozenge every 4-8 hours Like the gum you should not drink coffee, soda or other beverages with the lozenge. Nicotine Inhaler Nicotine inhaler and nicotine nasal spray both require a doctor’s prescription. As with the other nicotine medications, these are also started on the Quit Date. Learning about Healthy Living – Revised 2012 Page | 104

113 SECTION 5: Group I – Handouts 2012 ter 20 Cha p Nicotine inhaler is a plastic tube with a nicotine cartridge inside. When you puff on the inhaler, a nicotine vapor goes into the mouth. e the nicotine goes only into the It does not need to be inhaled sinc mouth and not into the lungs. Breathing or puffing on it too deeply will make you cough more. Holding the nicotine inhaler in your hand and puffing on it can seem li ke the closest thing to smoking a cigarette, which some smokers find helpful. Nicotine Nasal Spray delivers nicotine quickly and is absorbed Nicotine nasal spray through the nose. The nasal spray immediately relieves withdrawal control over nicotine cravings. symptoms and offers you a sense of Because it is easy to use and can deliver a bigger immediate dose of nicotine, smokers report great satisfaction with it. In the beginning, it has the most side effects and can cause sneezing, watery eyes and coughing although these usually stop if you keep using it. Bupropion Bupropion is a smoking treatment that does not contain nicotine. Bupropion can be used alone or in combination with nicotine medications to improve your chances of quitting. It is usually a personal choice to use bupropion. Some people are unable to take nicotine or prefer to take a pill medication to help them quit smoking. Bupropion can only be taken with a doctor’s prescription. the Quit date. It is It is usually started two weeks before recommended that you continue taking bupropion for 3-6 months after you quit smoking. Bupropion is EXACTLY the SAME medication as Wellbutrin SR or Zyban. Bupropion is also a good treatment for major depression. This medication should not be taken if you have a history of ting disorder), or head trauma. seizures, bulimia (binge and purge ea Learning about Healthy Living – Revised 2012 Page | 105

114 SECTION 5: Group I – Handouts 2012 ter 20 Cha p Varenicline (Chantix) Varenicline is a smoking treatment that does not contain nicotine and some studies have shown it is the most effective treatment currently available to help people stop smoking. Varenicline tricks your brain into thinking it is sti ll getting nicotine which helps take away nicotine withdrawal. It also blocks the pleasure associated with smoking. Varenicline is not used in combination with nicotine medications. Varenicline can only be taken with a doctor’s the Quit prescription. It is usually started one week before date. It is recommended that you continue taking varenicline for 3-6 months after you quit smoking. This medication should not be taken if you have a serious kidney disease. Some people get nausea when they take varenicline but this will be less if you take the medication with food. are available to help There are 7 medications that all the ones you would you stop smoking. (Check like to try)  Nicotine gum  Nicotine patch  Nicotine lozenge  Nicotine inhaler  Nicotine nasal spray  Bupropion (pill)  Varenicline (pill) Learning about Healthy Living – Revised 2012 Page | 106

115 SECTION 5: Group I – Handouts 2012 Cha ter 20 p Did you discuss these medicati ons with your doctor or nurse? _____ Yes _____ No Which one do you think would be best for you? Which medications require a doctor’s prescription?  Nicotine nasal spray  Nicotine gum  Nicotine patch  Bupropion (pill)  Nicotine lozenge  Varenicline (pill)  Nicotine inhaler Which medications contain nicotine?  Nicotine gum  Nicotine nasal spray  Nicotine patch  Bupropion (pill)  Nicotine lozenge  Varenicline (pill)  Nicotine inhaler Learning about Healthy Living – Revised 2012 Page | 107

116 SECTION 5: Group I – Handouts 2012 Cha p ter 20 Learning about Healthy Living – Revised 2012 Page | 108

117 SECTION 6: Group II - Facilitators Guide 2012 gg ested A roaches j Goals, Ob ectives & Su pp Group II: “Quitting Smoking” Goals, Objectives and Suggested Approaches the use of tobacco. All smokers with a desire The focus of Group II is to help smokers quit to try to quit smoking in the next month should be appropriate for Group II. Other positive indicators for treatment include a stro ng desire to stop smoking completely, past quit attempts, willing to use tobacco treatm ent medications and willingness to commit to attending all group treatment sessions. The type of participants recruited will largely determine the actual success rate achieved in any group, although combination treatment of tobacco treatment medications plus counseling are believed to yield the highest success rates. The added treatment effect of the gr oup setting partly comes from seeing others make quit dates and succeed. The clinician should be careful about including participants in Group II that are clearly stating that th ey are not ready to quit. Including these participants can contribute to a negative effect on the group, and/or the individual. Objectives for Group II: Quitting Smoking 1. Learn how to create a quit plan. 2. Learn what a quit date is. 3. Learn about how to achieve early abstinence from tobacco. 4. Learn about how to increase support for quitting. Chapter 1: Making a Quit Plan Objectives for this Chapter:  Review the components of a quit plan.  Learn to make a quit plan. After reading this section, individuals will be able to:  Take steps towards quitting and setting a quit date.  Begin to think about the steps involved in their own quit plan. Learning about Healthy Living – Revised 2012 Page | 109

118 SECTION 6: Group II - Facilitators Guide 2012 gg ested A roaches j Goals, Ob ectives & Su pp Suggested Approach:  After reading these pages, encourage individu als to talk about their own quit plans.  Discuss how setting an exact date, called th e quit date, allows the smoker to make preparations that can make the quit attempt more successful. Consider the pros and cons of having a quit date on a w eekday versus a weekend when less support may be available.  Compare a quit plan with a treament plan. Ask group members if they have input into their mental health treatment plan. How is the quit plan similar? How is it different? Chapter 2: Preparing to Quit Objectives for this Chapter: Set a quit date.   Change smoking patterns.  Remove all tobacco and tobacco related products from home and car.  Prepare medication plan with input fr om the physician or other prescriber. dividuals will be able to: After reading this section, in  Take steps towards quitting and setting a quit date.  Begin to think about the steps involved in their own quit plan, including preparing to use tobacco treatment medications. Suggested Approach:  Allow members to discuss aspects of their quit plan that may be different from others. Stress to the group that there is no “right” or “wrong” way to quit and that everyone may have a different approa ch that works best for them.  As members begin to quit, encourage them to use their nicotine medications (gum, inhaler, nasal spray, lozenge) in group so th at others may see this and ask questions. Reinforcing the use of medications to othe r group members is a positive approach that may encourage others to quit. Learning about Healthy Living – Revised 2012 Page | 110

119 SECTION 6: Group II - Facilitators Guide 2012 ectives & Su gg ested A pp roaches Goals, Ob j Chapter 3: Seeking support while you quit Objectives for this Chapter:  Review the benefits of having additi onal support during a quit attempt.  Encourage group members to seek additional support for quitting. After reading this section, in dividuals will be able to:  Begin to identify supports  Reach out to individuals, treatment provid ers, family, friends, support groups or internet sites for support for quitting. Suggested Approach: The New Jersey Quitnet is a free internet resource (http://nj.quitnet.com) that  allows smokers to log in as a member and participate in online chat rooms, email getting support for quitting smoking. groups and discussion forums focused on Allow members computer access to the internet after a group or have a demonstration of Quitnet resources. & Resources to Stay Smoke Free Additional Internet References American Cancer Society 1-800-ACS-2345 (1-800-227-2345) Internet address: www.cancer.org American Heart Association 1 800-242-8721 Internet address: www.heart.org American Lung Association 1 800-785-3355 Internet address: www.lung.org (Consumers Helping Others Improve CHOICES their Condition by Ending Smoking) 732-235-4341 Internet address: www.njchoices.org National Cancer Institute 1-800-4-CANCER or 800-422-6237 Internet address: www.cancer.gov Office on Smoking & Health, Centers for Disease Control and Prevention 1-800-CDC-INFO or 1-800-232-4636 www.cdc.gov/tobacco Internet address: Learning about Healthy Living – Revised 2012 Page | 111

120 SECTION 6: Group II - Facilitators Guide 2012 gg ested A roaches j Goals, Ob ectives & Su pp Nicotine Anonymous 1-877-TRY-NICA (1-877-879-6422) Internet Address: www.nicotine-anonymous.org cluding info on state QuitLines) (Online materials, in Smokefree.gov Internet Address: www.smokefree.gov Chapter 4: Refusing cigarettes Objectives for this Chapter:  Increase the group’s awareness of assertion and how to use it when refusing cigarettes Allow members to practice refusing cigarettes  After reading this section, in dividuals will be able to:  Consider the options they have when confronted with choosing cigarettes Practice techniques and tips that will help them to refuse cigarettes in high-risk  situations Suggested Approach: Do role-playing to help consumers go through the refusal skills steps. Put your consumers into teams of 2 or 3 and assign one or two of them the goal of persuading the other(s) to smoke cigarettes. The consumer in the role play who is being "persuaded" to smoke has to practice refusing the offer. After the exercise , lead your consumers in a discussion of the refusal skills used. Now repeat the exercise assigning different roles to each consumer in the groups. Allow consumers to coach each other with suggestions about how to handle these situations. Chapter 5: Dealing with setbacks Objectives for this Chapter:  Educate participants about relapses to av oid them feeling shame or disappointment  Remind the group that setbacks are common and most smokers try to quit a number of times before they are able to quit for good. Learning about Healthy Living – Revised 2012 Page | 112

121 SECTION 6: Group II - Facilitators Guide 2012 ectives & Su gg ested A pp roaches j Goals, Ob After reading this section, in dividuals will be able to:  Reduce disappointment related to a failed quit attempt Motivate participants towards quitti ng or making another quit date   logical addiction may have contributed to Understand aspects of physical or psycho their setback Suggested Approach:  Ways to Stay Motivated. Remind members that what they're do ing is not easy, so they deserve a o reward. o Put the money you would have spent on tobacco in a jar every day and then buy yourself a weekly treat. o Buy a magazine, go out to eat, call a friend long-distance. r a major purchase. Or save the money fo o o at don't cost money: take time out to You can also reward yourself in ways th read, work on a hobby, or take a relaxing bath.  ed quit attempt and make adjustments in Encourage participants to learn from a fail their quit plan, if needed .  Relapse prevention focuses on teaching sk ills that help peop le identify and cope with high-risk situations and moods, which might make them more likely to start smoking again. There is the opportunity to learn from past mistakes and use that information to make sure you stay quit for the rest of your life. For example, we know that high-risk situations or emotional st ates can be triggers for people to start smoking again. Some other typical cues for tobacco include seeing other people smoking, smoking after meals, or in response to interpersonal anxiety, anger, or is that by evaluating these high-risk depression. The idea of relapse prevention situations and being ‘on guard’ for them after you quit smoking; you will be less likely to start smoking again in the future!  For smokers with mental illness there may al so be additional or unique situations or symptoms, which contribute to smoking rela pse including boredom, or experiencing symptoms of paranoia, anxiety or depr ession. Weekends which have more unstructured time seems also to contribute to relapse in this group and our plan includes a weekend readiness topic. The facili tator’s role is to te ach skills such as self-monitoring of tobacco craving and cues , problem solving strategies, education about coping skills and self-control strategies. Learning about Healthy Living – Revised 2012 Page | 113

122 SECTION 6: Group II - Facilitators Guide 2012 ested A pp roaches gg j Goals, Ob ectives & Su Chapter 6: a Tobacco-Free Lifestyle Celebrating Quitting and Objectives for this Chapter:  Review the importance of celebrating quitting smoking Teach consumers how to reward themselve  s for taking steps towards quitting smoking After reading this section, individuals will be able to:  Conceptualize having a tobacco-free lifestyle  Begin to think about how they can have weekly rewards for themselves while they try to quit smoking Suggested Approach: Through modeling and instruction, teach members how to use positive  or behavior with the desired behavior. reinforcement to pair a positive thought Positive reinforcement will help participan ts’ reward them for any behavior change and feel good about quitting. Remind members that rewards need not be expensive- taking time out for personal  grooming, interests or simple hobbies can be very rewarding and affordable even on a fixed income.  Encourage group members to give positive feedback to other members- this group forcement will provide a strong social support and environment of positive rein reinforcer for the group. Learning about Healthy Living – Revised 2012 Page | 114

123 SECTION 7: Group II - Handouts 2012 Quitting Smoking Group Table of Contents: Group II Quitting Smoking Group CHAPTER CHAPTER TITLE PAGE Making a Plan to Quit 116 1 120 2 Preparing to Quit 123 3 Seeking Support While You Quit 125 4 Saying No to Cigarettes 5 Dealing with Setbacks 129 a Tobacco-Free Lifestyle 132 6 Celebrating Quitting and Learning about Healthy Living – Revised 2012 Page | 115

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125 SECTION 7: Group II - Handouts 2012 er 1 Chapt Making a Plan to Quit The two most important factors - 1. Make the decision to QUIT! 2. Set a Quit Date! There is no one right way to quit. Learn what methods are successful to others who have quit. You have to decide what will work best for YOU and then... Get the help you need to suppor t your decision to quit! Quitting smoking is not easy. Ther e are many professionals that can recommend to you what will be helpful in quitting. But this is only possible YOU make a promise to yourself to DO IT! Many people who try to if quit smoking wish that there were an easy way to do it – a method that would make quitting painless and easy. There is no painle ss or easy way to quit! You have probably used tobacco for a long time and it will take a commitment from you and reaching out fo r help from others...to succeed in your Quit Plan! Some people try cutting down on the amou nt of tobacco they use each day. This method is difficul t and may not work. Using tobacco treatment medications can help you. They will reduce your withdrawal symptoms. Bu t the most effective way to quit is when you use the proper treatment medications and become involved in a group or individual counseling . Using this method helps to address both the physical and psychologic al components of quitting. Learning about Healthy Living – Revised 2012 Page | 116

126 SECTION 7: Group II - Handouts 2012 er 1 Chapt Making the Decision to Quit The first step is making the decision to quit tobacco use. This is one that only you can make. you to quit, but the real Other people may want decision and commitment must come from you. Setting a Quit Date Once you've made the decision to quit, you're ready to pick a quit date. This is a very important step. Pick a spec ific day within the next few weeks as your ‘Quit Date’. Picking a date too fa r in the future allows you time to rationalize and change your mind. But be sure to gi ve yourself enough time and come up with a plan. You might to prepare what you need to do to quit want to choose a date that ke a birthday anniversary has a special meaning li or holiday. Or you can simply pick a random date. Circle the date on your calendar and then make a strong, personal commitment or promise to yourself to quit on that day. Making a Quit Plan Once you have made a decision to quit and have set a quit date, developing a list of other strategies that will help yo u quit is all part of your quit plan. Preparing yourself and your surroundi ngs before you quit will make it easier for you to achieve your quit goal. Learning about Healthy Living – Revised 2012 Page | 117

127 SECTION 7: Group II - Handouts 2012 er 1 Chapt Suggestions:  Get rid of ALL of your matche s, lighters and ashtrays.  Make a promise to yourself to NE VER SMOKE in your house or car.  Talk to your doctor and coun selor about quitting smoking.  Pick a person who you can talk to and be helpful to you. Learn about tobacco treatment medications and decide which ones  you may want to use. Learn about and visit a self -help or 12-step meeting   Get support from non-smok ing friends and family.  Make a list of situations that you would usually smoke and come up with a plan of how you will hand le those situations differently. Learning about Healthy Living – Revised 2012 Page | 118

128 SECTION 7: Group II - Handouts 2012 er 1 Chapt MY QUIT PLAN Name ______________________________________________ I have made a decision to quit smoking on________________. As part of my plan to quit smoking, I will: (check all that apply) Come to treatment sessions to talk about tobacco.   Read handouts  Talk to other people who used to smoke and learn about how they were able to quit quit. I will carry this with me in Make a list of all the reasons I want to  my pocket as a reminder. Begin to make smoking more diffi cult and more unpleasant for  myself. This means not smoking my favorite brand, not smoking in my favorite places and going outdoors to smoke.  Save the money I used to buy ciga rettes to do something or buy something special for myself. Each week, I will save $ ______________. I will use the money to: _______________________________.  My “Support Person” will be: ___________________________. He/She will help me to quit and re main without tobacco. Instead of smoking, I will try to talk to this person when I feel like I want a cigarette.  Make an appointment with my doctor to talk about tobacco treatment medications. Other Ideas for My Quit Plan ___________________________________________________ ___________________________________________________ Learning about Healthy Living – Revised 2012 Page | 119

129 SECTION 7: Group II - Handouts 2012 er 2 Chapt Preparing to Quit I am getting ready to quit using tobacco. I will try to make preparations to quit. I believe doing the following things will help to make my quit attempt more successful: 1. I will not buy large amounts of ciga rettes or other tobacco products, like cartons of cigarettes, for example . It is better to buy cigarettes one pack at a time since I am getting ready to quit. My goal is to run out of cigarettes on my quit date. Get rid of all my tobacco or cigare 2. tte related items. This includes ashtrays, lighters and even t-shi rts or other items with tobacco company names or logos. These thi ngs remind me of smoking. I will be more successful in quitting if these things are not in my home. 3. Remove ashes from my car ashtray and places in my home because I know that smelling cigarettes afte r I quit could make me want to smoke. 4. Talk to someone about my plans to quit tobacco. This can be a roommate, friend or signi ficant other. I will let them know when my quit date will be. 5. Keep trying to make it difficult or unpleasant to smoke. I will try to make smoking easy. break all habits that Learning about Healthy Living – Revised 2012 Page | 120

130 SECTION 7: Group II - Handouts 2012 er 2 Chapt I will set a quit day. One to two weeks before my quit date, I will:  Pick the date and mark it on my calendar. Tell friends and family member s that I will quit smoking   s and arrange to see my doctor Decide on a plan for medication uld be my group class, or non-  Set up a support system. This co smoking family or friends wh o are willing to help me  Varenicline if that is part of my Start using the medicine Bupropion or quit plan. On the night before my quit date, I will:  ashtrays, and any other items related Get rid of all cigarettes, lighters, to smoking. Smoke my last cigarettes and say “goodbye” to cigarettes.  On my quit date, I will:  Not smoke.  Keep active - try walking, exercisi ng, or doing other activities or hobbies I enjoy doing. Drink water and use mints or hard ca  ndy to help me with the cravings for cigarettes. Begin using nicotine medications if that is part of my quit plan.   Contact my counselor or therapist who will help me stop smoking.  Avoid other smokers.  Avoid places and situations where the urge to smoke is strong. Learning about Healthy Living – Revised 2012 Page | 121

131 SECTION 7: Group II - Handouts 2012 er 2 Chapt List ways you can get ready for your quit date. 1 week before: The night before: MY QUIT DATE WILL BE: Learning about Healthy Living – Revised 2012 Page | 122

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133 SECTION 7: Group II - Handouts 2012 er 3 Chapt Seeking Support While You Quit You will have a better chance of quitting successfully if you have help and support from your health professional, family, friends, and coworkers. A doctor or mental health professional can help you tailor an approach to quitting smoking that best suits your physical and emotional needs. These people are also good sources of moti vation and support during the quitting process. Talk to ex-smokers about their exper iences during and after quitting. People who have quit smoking may be particularly helpful, because they know what you are going through. If you live with someone who smokes, let that person know specifically how quit smoking. Talk with him or her he or she can support your efforts to about not smoking in front of you. Be tter yet, ask that person to quit smoking with you. That way you ca n support each other through the quitting process. Family and friends can help support and encourage you while you are quitting. Remember this group will he lp you quit smoking . The more counseling you get, the better your ch ances of quitting. Counseling should with situations that tempt you to help you learn to recognize and cope smoke and provide information about successful quitting strategies. Use the Internet cess to information about . The Internet allows free ac quitting smoking and to chat rooms that can provide support for a person wanting to quit. One good internet site is: www.nj.quitnet.com/ NJ Quitnet ( ) Learning about Healthy Living – Revised 2012 Page | 123

134 SECTION 7: Group II - Handouts 2012 Chapt er 3 Getting support from your friends and family is very important when you’re quitting smoking. Can you list some people who you ca n get support from while you quit smoking? Do you belong to any support groups th at could help you quit smoking? ______Yes, Describe: ___________________________________ ______ No Learning about Healthy Living – Revised 2012 Page | 124

135 SECTION 7: Group II - Handouts 2012 er 4 Chapt Saying No to Cigarettes The most common reason that people go back to smoking after quitting is because they saw another smoker or were offere d a cigarette by a smoker. Therefore, it’s a good idea to plan ‘how’ to say no when this happens (and it will happen eventually!). Practice in this group or in front of a mirror what you would say if someone offered you a cigarette. Examples:  ‘No thanks Dan, I don’t smoke anymore’ ‘Thanks for offering Dan, but I quit  smoking and don’t want to smoke ever again’ ‘No thank you Dan, I’m a non-smoker now’  Besides practicing by yourself, you can pr actice role-play situations in this group. You can practice how to say no to cigarettes and practice other high- risk situations that make you want to smoke. To assist in learning how to refuse cigarettes, use these fi ve steps in refusal skills:  Ask questions Recognize when you’re in trouble  Think about the consequences   Suggest other activities Get out of there  Learning about Healthy Living – Revised 2012 Page | 125

136 SECTION 7: Group II - Handouts 2012 Chapt er 4 Ask yourself these questions  Is it really possible for me to have just one cigarette?  Do I really want this cigarette enough to give up on everything I have been working on? Can I wait for 7 minutes and see if the urge passes?  Recognize when you’re in trouble One cigarette will probably lead to many more! I always end up smoking when I am: List a place: ________ ____________________________ List a person: ________ _______________ ____________ Think about the consequences I will start coughing again if I smoke. I will start spending $__________ per week on cigarettes if I start smoking again. I have been enjoying using that money I have saved on: _____________________________________________ Learning about Healthy Living – Revised 2012 Page | 126

137 SECTION 7: Group II - Handouts 2012 Chapt er 4 Other activities I can suggest to do instead of smoking:  Let’s go for coffee  Let’s go indoors and talk  Let’s go for a bike ride Other suggestions:  ___________________________________________ 1. 2. ___________________________________________ 3. ___________________________________________ Get out of there! If you feel tempted to smok e, GET OUT OF THERE! I will leave now and go to a non-smoking place: _________________ ______________________ Learning about Healthy Living – Revised 2012 Page | 127

138 SECTION 7: Group II - Handouts 2012 er 4 Chapt SAY NO THANKS! Who are some people in your life who you could imagine offering you a cigarette in the future? 1. _____________________ ____________________ ____________________ 2. _____________________ _____________________ ____________________ 3. What are some things you can say if people offer you cigarettes? _____________________ 1. ____________________ 2. _____________________ ____________________ 3. _____________________ ____________________ Learning about Healthy Living – Revised 2012 Page | 128

139 SECTION 7: Group II - Handouts 2012 er 5 Chapt Dealing with Setbacks You may have been unsuccessful in your last quit attempt. Maybe even in your last few quit attempts. When this happens, it is common to feel ed. This feeling may have discouraged disappointed or feel like you have fail you from trying again. most smokers try Remember that research has shown that to quit a number of times before they are able to quit for good. ts as practice for the day you will  Try thinking of your previous attemp quit forever.  Instead of blaming yourself, think about all that you have learned from each attempt that will be helpful to you now.  If you use tobacco again, don’t be too hard on yourself. Forgive yourself and remember it take s courage to quit smoking.  e a failure or that One slip does not mean that you ar you cannot be a nonsmoker.  If you slip, it is important to ge t yourself on the nonsmoking track immediately. Review your triggers and coping skills, and try again. IMPORTANT POINT TO REMEMBER: Research has shown that most smokers try to quit a number of times before they are able to quit for good. Learning about Healthy Living – Revised 2012 Page | 129

140 SECTION 7: Group II - Handouts 2012 er 5 Chapt Slip or Relapse What if you do smoke? The difference between a slip and a relapse is within your control. When you have a slip, it means that you had a cigarette without thinking things through. You have a choice at this point! You can use the slip as an excuse to go back to smoking, or you can look at what went wrong and renew your commitment to staying off smoking for good. What reasons stopped you from achieving your goals? Physical Addiction/ Withdrawal symptoms are most severe within the first Remember that withdrawal symptoms  1 to 3 days of abstinence, and can often continue for several weeks. The physical symptoms of withdrawal, while annoying, are not life threatening. Nicotine replacement or medications can help reduce many of these physical symptoms.  In addition, if these symptoms were severe and caused you to smoke, you could be successful in future quitting if you used more or different medications. Psychological Addiction  If you have been using tobacco for any length of time, it has become linked with many of your activi ties - watching TV; attending sport iving your car. It will take time events; while fishing, camping, or dr Learning about Healthy Living – Revised 2012 Page | 130

141 SECTION 7: Group II - Handouts 2012 er 5 Chapt to "un-link" smoking from these activi ties. That is why, even if you are using medications, you may still have strong urges to smoke.  If these psychological reasons caused you to smoke, you could be successful in future quitting if you used more or different support and counseling treatment. IMPORTANT TIP TO REMEMBE R If you have recently tried to quit and slipped up or started smoking again, just get right back on track – you haven’t lost any time and will probably be more successful this time if you learn from your mistakes in the past! ed to quit smoking. Remember the reasons you want ___________________________________________________ ___________________________________________________ ld avoid to stay smoke-free? Where are the places that you shou ___________________________________________________ ___________________________________________________ What are some habits you can change that could make a difference while trying to quit? ___________________________________________________ ___________________________________________________ Learning about Healthy Living – Revised 2012 Page | 131

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143 SECTION 7: Group II - Handouts 2012 er 6 Chapt Celebrating Quitting and a Tobacco-Free Lifestyle Quitting smoking is some thing to celebrate! Although there will be some challenging times, ant decision to live a you have made an import healthier lifestyle! Stay Positive  Quitting smoking is one of the best things you can ever do for your body. It is an amazing accompli shment to quit smoking.  You should be very pr oud of trying to quit.  Focus on your goals  Write down your personal reasons for quitting  Hang them on your refrigerator an d keep them in your wallet and look at them as often as possible. Give yourself personal rewards  Celebrate quitting smoki ng as often as you can  Give yourself small reward s: a small gift or treat  Low cost rewards are things you find pleasant: a bubble bath, an enjoyable book, a bike ride, list ening to your favorite music Learning about Healthy Living – Revised 2012 Page | 132

144 SECTION 7: Group II - Handouts 2012 er 6 Chapt Remember the social rewards  Imagine yourself telling people you are a nonsmoker  Ask for a nonsmoking table in a restaurant  Attend non-smoking bingo  Give tips to a friend about how to quit smoking,  Imagine other people coming to you saying WOW! how did you do it?! A TOBACCO-FREE LIFESTYLE Maybe you have quit smoking many times before and eventually started derstand that it’s not just quitting smoking again. At this point, you un that’s important but , which can be difficult. Staying quit STAYING QUIT is the final, and most important, stag e of the quitting smoking process. You can use the same methods to stay qu it as you did to help you through withdrawal. Think ahead to those times when you may be tempted to smoke, and plan on how you will use alternatives and activities to cope with these situations. More dangerous, perhaps, are the un expected strong desires to smoke that occur sometimes months (or even years) after you've quit. To get through these without relapse, try the following: Review your reasons for quitting and think of all the benefits to your  health, your finances, and your family.  Remind yourself that there is no su ch thing as just one cigarette - or even one puff. , but do not fool yourself into  Ride out the desire. It will go away thinking you can have just one. Learning about Healthy Living – Revised 2012 Page | 133

145 SECTION 7: Group II - Handouts 2012 er 6 Chapt REWARD YOURSELF! List some things you can do to re ward yourself weekly as you quit (Remember, you can use some of the money you smoking? would normally spend on ci garettes to do something nice for yourself!) _______________________ ______________________ _____________________________________________________________________________ _______________________ ______________________ What are 3 things you can do to maintain a tobacco-free lifestyle? __________________ ____________________ 1. __________________ ____________________ 2. 3. __________________ ____________________ Learning about Healthy Living – Revised 2012 Page | 134

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147 Table of Contents: Appendix/Forms PAGE FORM NAME Consumer Self-Report Tobacco Assessment 136 On the Path to Healthy Living Questionnaire 138 Tobacco Dependence Plan 141 Instructions for Carbon Monoxide (CO) Monitoring 142 Learning About Healthy Living / Group Record Sheet 143 Group Reminder Card 144 I’m Not Ready to Quit Smoking 145 Body Mass Index (BMI) 146 My Pyramid Worksheet 148 Resources 149 References 151 Learning about Healthy Living – Revised 2012 Page | 135

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149 Consumer Self-Report Tobacco Assessment Today’s Date: ________________ Name: __________________________________ Gender: M F Date of Birth: ___________________________ Age: __________ Tobacco Use – 1. Please check the appropriate bo x for each type of tobacco: Never Used 1a CIGARETTES Used in the Past Currently Use 1b PIPE Never Used Used in the Past Currently Use 1c CIGARS Never Used Used in the Past Currently Use 1d CHEWING TOBACCO Never Used Used in the Past Never Used Currently Use 2. What age were you when you first used or tried tobacco? 3. What age were you when you started using tobacco on a regular basis? 4. How many cigarettes do you smoke each day? 5. How many minutes after you wake up do you st smoke your 1 cigarette? en at night to have a 6. Do you sometimes awak Yes _____ cigarette or use tobacco? No _____ 7. Who smokes in your household? Please check all that apply: No One Parents Brothers/Sisters Significant Other Roommates Yes ___ No ___ 8. Do you smoke indoors at home? Learning about Healthy Living – Revised 2012 Page | 136

150 important is it to you to stop tobacco us e now? Please check one box. 9. How 1 2 3 4 5 6 7 8 9 10 Aver age Importance Extremely Not at All Important Tobacco-Related Illness 10. Have you in the past or do you now have any of the following? (Check all that apply) Arrthymia/ Emphysema Obesity/ Irregular Heart Beat Overweight Asthma or Halitosis/ Peptic Ulcer Bad Breath Chronic Bronchitis Cancer (List Type Below) Heart Attack/ Pneumonia Disease Circulatory Problems Impotence Seizures Diabetes Infertility Stroke Early Menopause Wrinkles Influenza/ Frequent Flu Other illness (describe): Desire to Quit 11. Please check the number next to the one statement that best describes your current situation: 11a I currently smoke/use tobacco an d I do not want to quit in the next 6 months. 11b I am seriously considering quit ting in the next 6 months, but not in the next 30 days 11c I am interested in drastically reducing the number of cigarettes I currently smoke (reduce by half or more), but am not interested in quitting totally. 11d I am interested in quitting smoking/tobacco use in the next month, and I would be interested in any assistance I could get. in stopping your tobacco use 12. How confident are you that you will succeed now? Please check one box. 1 2 3 4 5 6 7 8 9 10 Not at All Aver age Importance Extremely Important Learning about Healthy Living – Revised 2012 Page | 137

151 On the Path to Healthy Living Questionnaire ink about your overall health. These Here are some questions to help you th questions can also help you begin a discussion with your health care professional. Remember, you don’t have to tackle all of these questions today. Just reading this list is already a step on your path to Healthier Living. Physical Health Has it been over a year since the date of my last physical exam?  yes  no If yes , is there anyone I can call to make an appointment for a  no  unsure checkup?  yes Do I have a regular primary care provider (PCP)?  yes  no If yes , who can I call?_________________________ If no , do I know how to find a PCP in my community?  yes  no unsure  yes Do I have any physical health problems that I know of?  no  unsure (For example: high blood pressure, di abetes, or a problem with my weight.) If yes, can I list all of my physical problems?  yes  no  unsure _____________________________________ _____________________________________ Do I take any medication for these problems?  yes  no If yes, can I list the medications?  yes  no  unsure _____________________________________ _____________________________________ Do I have any problems with my hearing?  no  unsure  yes If yes , who can I call?____________________ Has it been more than six mo nths since the date of my last dental exam?  yes  no If yes , who can I call to make an appointment for a check-up? ___________________________________________ Weight/Nutrition What is my weight? _____ What is my height? ____ Learning about Healthy Living – Revised 2012 Page | 138

152 ss index (BMI)*? _____ What is my body ma Am I at a healthy weight?  yes  no  unsure How many beverages with sugar do I drink per day? _____ (soda, juice, coffee, etc.) Should I cut down on beverages with sugar?  yes  no  unsure Do I snack on “junk” food (cookies, chips, candy, etc.)?  yes  no What healthier snacks might I like to eat? _______________________________________________________ _______________________________________________________ Do I eat seconds or large po rtions frequently?  yes  no  unsure Should I cut down on the amount of food that I eat?  yes  no  unsure Do I eat dessert (cake, cookies, ice cream, etc.) frequently?  yes  no  no  unsure Am I eating healthy foods?  yes , what are some things I can change about my diet to live healthier? If not __________________________________________________ * A Body Mass Index (BMI) chart is incl uded. Please ask your health care professional how to figure out your BMI if you do not know how to do this. Smoking Do I smoke?  yes  no If yes, how many cigarettes do I smoke per day? _____ Am I interested in cutting down or quitting?  yes  no  unsure is now the time for me to quit smoking?  yes  no  unsure If yes, Do I know where can I find help quitting smoking?  yes  no  unsure If yes , where: _________________________ Physical Activity/Sleep /Stress Reduction What type of physical acti vity do I do regularly?_______________________ Learning about Healthy Living – Revised 2012 Page | 139

153 Do I get enough physical activity?  yes  no  unsure How much sleep do I get? ___________ Do I wake up feeling rested?  yes  no If no, do I know what I can do about it?  yes  no who can ask? If no, __________________  no  unsure Do I generally feel a lot of stress?  yes  no  unsure Do I participate in any activities that help me relax?  yes How many beverages with caffein e do I drink per day? ____ Should I cut down?  yes  no  unsure reduce my overall stress level Name one helpful thing that can help (such as deep breathing): _____________________________________ My Team t team who may be able to help in my Below is a list of people on my treatmen journey for physical health and wellness. Check the people I think may be of help: My psychiatrist  yes  no  unsure My nurse  yes  no  unsure My therapist  yes  no  unsure My case manager  yes  no  unsure My family doctor  yes  no  unsure A family member  yes  no  unsure A friend  yes  no  unsure My clergy  yes  no  unsure Another mental health consumer  yes  no  unsure Community resource (such as the YMCA) write in:________________ What are the names of one or two ot her people who can help me with t my physical health/wellness. questions/issues that I have abou _______________________________________________________ Learning about Healthy Living – Revised 2012 Page | 140

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155 Tobacco Dependence Treatment Plan Patient Name: _________________________________________ Problem: Tobacco Dependence as evidenced by spen ding a great deal of time smoking, use despite known dangers of tobacco use, to lerance (increasing use over time to obtain desired effect). Patient is unab le to abstain from smoking during illness and noted medical problems: ______________________________________________________ CO Reading ______ Level of Motivation: ___Pre-contemplati on ___Contemplation ___Preparation ___Ac tion Goal: To reduce or elimin ate use of tobacco Objectives: 1. Client will acknowledge that to bacco use is a problem for them. 2. Client will attend gain knowledge ab out the effects of their tobacco use by attending the Learning about Heal thy Living Group on a weekly basis. 3. Client will learn about the medical complications caused by tobacco use and be able to identify personal medical concerns. medications to prevent and reduce 4. Client will learn about treatment able to identify thei withdrawal symptoms and be r preference to use. with the assistance of staff. 5. Client will develop a quit plan Client will set a quit date and begin to abstain from smoking. 6. Client will progress from the educat ional/motivational group to the quit 7. group. Interventions: 1. Attend Learning about Healthy Living _____ Education/Motivational Group _____ Quit Group 2. Client will meet weekly with Physician ________________ to discuss appropriate use of tobacco dependence treatment medications. 3. Treatment staff will help identify alternatives to trigger situations. ____________________________ __________________ Date Signature of Clinician Learning about Healthy Living – Revised 2012 Page | 141

156 Instructions for Carbon Monoxide (CO) Monitoring It is important to show your client how the CO Monitor works and what the purpose of it is.  Carbon monoxide or CO is a poisonous gas.  CO has no color and no smell.  It is found in car exhaust fumes and in tobacco smoke.  CO deprives the body of oxygen it needs to live.  Smokers can have 2-20% of their normal blood oxygen taken up by CO.  This lack of oxygen increases the risk of damage to the heart muscles, can affect your ability to concentrate and can make you tired. How to use the piCO+ Smokerlyzer: similar - please consult your (note: other monitors work owner’s manual) Turn on the monitor by holding do wn the button for three seconds. 1. Attach a breath sampling D-piece and new mouthpiece. 2. Inhale and double click button to start a breath test. 3. 4. Hold breath for the 15-second countdown. 5. A beep will sound during the last three seconds of the countdown. 6. Blow slowly into the mouthpiece, aiming to empty lungs completely. (COHb) levels will rise and hold. The 7. The ppm and equivalent % carboxyhaemoglobin colored LED’s will light accordingly. 8. purge the sensor with fresh air. Remove the D-piece between tests to 9. To repeat the breath test, double click the button to return to main display and continue from step 2 above. 10. To switch off, hold button for 3 seconds. Until will auto power off after 5 minutes of inactivity. taking a CO reading: Patient Directions for re them that once you begin you will remind Tell your client the directions and then reassu them as they go along. 1. Sit up straight in the chair with both feet flat on the floor. 2. When I say go, you will take a deep breath and hold it for 15 seconds. 3. The machine will help you count down for 15 seconds 4. When it gets to zero, close your lips tigh tly around the cardboard tube and blow out (exhale) into the tube for as long as you can. 5. Do not blow too hard or it can affect the reading by disengaging the valve pin in the monitor. 6. View output number and explain the reading to your client. 7. (OPTIONAL) Change ppm setting to % to view estimated percentage of red blood cells which are carrying CO instead of oxygen esults. Respond positively Patients are often curious and concerned about th eir assessment r to any curiosity expressed, since this is a sign of treatment engagement. Be sure to explain in clear and simple language the meaning of the CO reading and the fact that with abstinence from tobacco CO levels return to normal within 24 hours. Learning about Healthy Living – Revised 2012 Page | 142

157 NRT Meds/ CPD CO Group Date NRT Meds/ CPD CO Group Date NRT CPD Meds/ CO Date Group y, Meds/NRT=Tobacco Treatment Medications in Week and Group information for NRT Meds/ CPD CO Date Group Learning About Healthy Living / Group Record Sheet If client is Absent, please put “A” ssessment A Information Date CO CPD CO=Carbon Monoxide, CPD=Cigarettes Per Da Name 1 7 7 5 3 2 6 4 9 8 11 1 15 13 12 14 16 19 18 10 20 Learning about Healthy Living – Revised 2012 Page | 143

158 GROUP REMINDER “Guide to Healthy Living” The next group will be held on ______________, _______ ______ ____ ___ , _____ Day of Week Month Date Year The topic will be: If you cannot attend this group, please contact: Name: ___________________ ____________________ _______________________ Phone: ________________ GROUP REMINDER “Guide to Healthy Living” The next group will be held on ______________, _______ ______ ____ ___ , _____ Day of Week Month te Year Da The topic will be: If you cannot attend this group, please contact: ____________________ Name: ___________________ _______________________ Phone: ________________ Learning about Healthy Living – Revised 2012 Page | 144

159 I’m Not Ready to Quit Smoking . . . but, I am Ready to: Come to group to talk about tobacco.   Read handouts  Talk to other people who used to smoke and learn about how they were able to quit  Count and keep track of how many cigarettes I smoke each day.  Recognize my smoking patterns.  Delay smoking at certain times. Make it more difficult for myself to smoke. I can move my cigarettes  from their usual place. I can smoke with my other hand or do things that are not my usual smoking “habit”.  Try to reduce my carb on monoxide level.  Ask my family and friends how they f eel about my smoking. Ask them if they would be able to help me when I try to quit.  Calculate how much I spend on tobacc o each week, each month and each year.  Think about the benefits of quitting smoking for me personally.  Change my smoking.  I’m beginning to think seriou sly about quitting smoking. Learning about Healthy Living – Revised 2012 Page | 145

160 Body Mass Index (BMI) ody M ass B ndex or BMI is a measure of body fat based on height and weight I that applies to both adult men and women. If the BMI goes above the normal range (25), the risk for some diseases such as heart disease, high blood pressure, diabetes, arthritis, some cancers and even premature death increases. The higher the BMI goes above normal, the higher the ri sk. For adults, BMI falls into one of these categories: BMI Weight Status Below 18.5 Underweight 18.5 – 24.9 Normal 25.0 – 29.9 Overweight Obese 30.0 and Above Source: http://www.nhlbisupport.com/bmi/ What is My BMI? If you know your height and weight, a BMI table can be used to figure out your BMI. To use the table, find your heig ht in inches in the left-hand column labeled “Height.” Move across to your weight in pounds. The number at the top column is the BMI at th at height and weight. For example, if someone is 5 feet and 4 inches (64 inches) and weighs 174 pounds, their BMI = 30. This example is highlighted in yellow on the table. Learning about Healthy Living – Revised 2012 Page | 146

161 20 21 22 23 24 25 26 27 19 29 30 31 32 33 34 35 BMI 28 Height Body Weight (pounds) (inches) 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 58 167 162 59 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 94 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 60 61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 63 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 107 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 162 65 120 126 132 138 144 150 156 114 168 174 180 186 192 198 204 210 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 184 125 138 144 151 158 164 171 177 131 190 197 203 210 216 223 230 68 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 69 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 71 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 136 72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 74 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 148 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 230 76 164 172 180 189 197 205 213 221 156 238 246 254 263 271 279 287 Source: http://www.nhlbisupport.com/bmi/ What is your BMI number?______________________ Learning about Healthy Living – Revised 2012 Page | 147

162 MyPyramid Worksheet On the following MyPyramid Worksheet, check how out how healthy your food choices are.* Worksheet is base d upon a 2,000 calorie pattern Find out how many calories you need in a day by going to the web http://www.choosemyplate.gov/food- groups/downloads/MyPyramid_Getting_Started.pdf Source: http://www.choosemyplate.g ov/downloads/Archived MyPyramid/Worksheet_3200_18.pdf Accessed February 2012 Learning about Healthy Living – Revised 2012 Page | 148

163 Resources There are many things you can do to seek additional help about your smoking, even if you are not ready to quit. Some possibilities include:  Talking with your counselor or therapist  ons with your doctor or nurse Discussing tobacco treatment medicati  Attending a group for people who want to quit smoking  Finding out more information on the internet: American Cancer Society 1-800-ACS-2345 (1-800-227-2345) Internet address: www.cancer.org American Heart Association 1-800-242-18721 Internet address: www.heart.org American Lung Association 202-785-3355 Internet address: www.lung.org CHOICES (Consumers Helping Others Improve 732-235-4341 their Condition by Ending Smoking) Internet address: www.njchoices.org 1-800-4-CANCER (1-800-422-6237) National Cancer Institute www.cancer.gov Internet address: Office on Smoking & Health, Centers for 1-800-CDC-INFO (1-800-232-4636) Disease Control and Prevention Internet address: www.cdc.gov/tobacco QuitNet quitnet.com/qnhomepage.aspx Internet address: http://www. Nicotine Anonymous 1- 877-TRY-NICA (1-877-879-6422) Internet Address: www.nicotine-anonymous.org Smokefree.gov (Online materials, including info on state QuitLines) Internet Address: www.smokefree.gov University of Medicine and Dentistry of NJ CINJ-RWJMS-SPH Tobacco Dependence Program (732)-235-8222 www.tobaccoprogram.org Internet Address: Learning about Healthy Living – Revised 2012 Page | 149

164  Call a free telephone counseling service: Call from anywhere: 1-877-44U-QUIT (1-877-448-7848) Smoking cessation counselors from the National Cancer Institute are available to answer smoking-related questions in Englis h or Spanish, Monday through Friday, 8:00 a.m. to 8:00 p.m. Eastern Time. NOW (1-800-784-8669/TTY 1-800-332-8615) Help within your state: 1-800-QUIT This toll-free telephone number connects you to counseling and information about quitting smoking in your state. Always remember:  People who use medications to quit are twice as successful as those who quit cold turkey.  You and your doctor will need to disc uss which medication or medications will be best for you. Learning about Healthy Living – Revised 2012 Page | 150

165 References American Cancer Society. Cancer Facts and Figures 2012. Atlanta, GA. 2012. Retrieved 3/1/12 from: http://www.cancer.org/acs/groups/content /@epidemiologysurveilance/documents/document/acspc-031941.pdf Agency for Health Care Policy and Research, Cl inical Practice Guideline on Smoking Cessation, No. 18, AHCPR, Rockvi lle, MD, April 1997. Centers for Disease Control and Prevention (CDC). Annual smoking-attributable mortality, costs - United States, 1995-1999.MMWR Morb years of potential life lost, and economic Mort Wkly Rep. 2002;51 300-303. Available online at www.cdc.gov/mmwr//preview/mmwrhtml/mm5114a2.htm. Accessed October 2003. Centers for Disease Control. Best practices for comprehensive tobacco control programs -- August 1999. Atlanta, GA: US Department of Health and Human Services, Public Health Service, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1999. Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco Control Programs—2007. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Ce nter for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; October 2007. Reprinted with corrections. Retrieved 3/3/12 from: http://www.cdc.gov/tobacco/stateandcommunity/best_practices/index.htm Centers for Disease Control. BMI -Body Mass In dex: BMI for Adults. 2004. Retrieved 3/1/12 from: http://www.cdc.gov/healthyweight/assessing/ bmi/adult_bmi/index.html. Centers for Disease Control. Body Mass Index Table. Retrieved 3/1/12 from: http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm , 2004. utable mortality, years of potential life lost, Centers for Disease Control (CDC). Smoking-attrib and economic costs- United States, 2000-2 004. MMWR Morb Mort Wkly Rep, 2008; 57(45);1226-1228. Retrieved 3/1/12 from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm -analysis of worldwide studies demonstrating an association de Leon J, & Diaz FJ. A meta between schizophrenia and tobacco smoking behaviors. Schizophrenia Research, 2005, 76(2–3), 135–157. Desai HD, Seabolt J, & Jann MW. Smoking in pati ents receiving psychotropic medications: A pharmacokinetic perspective. CNS Drugs, 2001, 15(6), 469–494. Evins AE, Cather C, Deckersbach T, Freudenrei ch O, Culhane MA, Olm-Shipman C, et al. A double-blind placebo-controlled trial of bupropion sustained-release for smoking ical Psychopharmacology, 2005, 25(3), 218– cessation in schizophrenia. Journal of Clin 225. Learning about Healthy Living – Revised 2012 Page | 151

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