>>> hello, everyone. Thank you for joining us today. We will be starting our webinar in a moment and would like to get participants a chance to dial in and settle down. good afternoon, everyone. And welcome to our webinar. Assisting clients with quitting how to talk the talk part one. Hosted by the national behavioral health network in partnership with the smoking cessation leadership center at the university of California San Francisco and the center of excellence for tobacco-free recovery. Thank you so much for joining us today. If you are a participant that needs access to closed captioning please see the link on the screen. That is also available in the chat box. I am the project coordinator for the National Council Behavioral Health. I will be serving as your moderator for today's webinar. I'd also like to introduce you to our presenter for today's webinar. National director of the pharmacy partnership for tobacco cessation and clinical assistant professor at Purdue college of pharmacy. I'll be turning it over to him in a few minutes after we have some coverage for housekeeping and introductory items. Today's webinar is being recorded, and all participants will be kept in listen-only mode. You can dial in through phone or computer audio to listen in. Questions may be submitted throughout the webinar. Type in your question into the Q&A panel or chat box. We will have a copy of handouts available for download on our webinar archives page. In addition the link for closed captioning of our presentation can be found on screen or in the chat box. At the end of our webinar, a short post webinar survey will show up on your screen. Please be sure to leave us your valuable feedback. Before we get into the contents of today's webinar, I'd first like to provide a brief overview of the National Council Behavioral Health for tobacco and cancer control that is hosting today's presentation, also known as NBHN. This is one of the networks seeking to eliminate cancer in populations. We provide webinars like today's, communities of practice and many other valuable resources and information. All focused on addressing tobacco and cancer disparities and individuals with mental illness and addiction. Please visit the website to gain access to helpful resources and information. Also I'm happy to share that registration is open for the national council's annual conference, NATCON taking place in Austin, Texas, in April. You can learn more and register, click the events tab and then clicking NATCON 2020. 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Please note that there may be different or additional requirements depending upon your profession. After the webinar you will receive an email from Jennifer at the smoking cessation leadership center with instructions on how to claim CME credits. I will hand it over to the national director of pharmacy partnership for tobacco cessation. >> Good afternoon, everybody. Just a very brief introduction of my background. I've been doing cessation counseling, program design, and trainings for 33 years now. The last 20 or some years, I have focused on providing training, similar to what we're doing today. I have trained probably 25, 30,000 people over all these years and I've counselled probably about 10,000 patients myself in various research projects and just private cessation counseling. So I tell you all that so that you can be comfortable asking me any question that you want. I pretty much think I've encountered almost everything out there at this point in my career. And you will have my contact information at the end of this presentation. So please don't hesitate to ask any type of question. As you were just told though, the questions will be moderated. So type them in and hopefully we can have time to get to yours. So this is the first part of a two-part presentation. I would strongly encourage everybody to take the second part on Monday. And the reasoning behind this is that smoking, very clearly, has two distinct aspects to it. It is not only a physical addiction to nicotine, but it's also a behavior, it's a habit. So in order to quit successfully, you must help your patients deal with both of these aspects simultaneously. So, there are two parts to smoking, there are two parts to quitting. Today we're going to look at very briefly the behavioral part, and then on Monday we will go over the seven FDA-approved medications to help your patients get over the physical addiction to nicotine. Now the presentation that I'm going to do today and on Monday comes from. This is a curriculum that was designed by Karen HUDMON. UCSF. Probably now it's been 15 years ago, for pharmacy schools. I had designed a program years ago to train pharmacists and other healthcare professionals who already practice. And what we discovered is that it's much more difficult to get people to change behavior, as you're probably all aware, after they have been doing something for 10, 20, 30 years than it is to introduce a new concept, a new idea to students. So we created this as a curriculum for pharmacy students. I'm happy to say at that time all but one pharmacy school in the country adopted it. And we've since expanded it to emergency doctors. There is a psychiatric version of it, respiratory therapy, peer counselors. So if you go to the website, you will get the full presentation of which I'm only going to do about 35, 40 minutes. Assisting patients with quitting, assisting clients with quitting probably is about two and a half hours. So there are notes under every slide so you can kind of go through this on your own as a training if you want more information on this. There is all kinds of other things on that website that would help -- that'll help you learn including videos to give you samples of how to do counseling. There are scenarios for patients for doing -- oh, gosh, I'm blocking on the word -- when you're doing standardized patients. I'm sorry, I just couldn't think of the word. So if you're in a situation where you use standardized patients in a classroom, there is information there. There are many handouts that you can access. So it's all under our expert change. It's in the upper left-hand corner. And I will reference that at the end again too next week. So let's jump the slide here. As I said, this is a two-part problem. So the treatment has two parts. Today we're going to focus on the behavioral change and then on Monday we will focus on the addiction to nicotine and the medication. The evidence shows clearly that the best way to help someone quit is to do both of these at the same time. So we want you to encourage your patients -- your clients -- I'm sorry. I'm so used to using the word patients because I train mostly physicians and pharmacists. So please excuse me if I use that. I'm going to use the term clients. When you treat your clients you need to have them use one of these medications to get over the addictions while they are making the behavior changes. And I want to point out here, since all of you or most of you are in behavioral health that the evidence is overwhelming that people with behavioral health or substance abuse issues can quit just as successfully as people in the general population. The whole point here is that there is no one single right way to help anybody quit. Everything has to be tailored to the individual. So as long as you are taking this into account, your particular client's issues and their individual situations, you will be just as successful with someone who is in the general population. Now, if you have someone who is schizophrenic and they're in the middle of an episode where they're hallucinating or you have someone who has substance abuse and they're drinking and they're using, that might not be the best time for them to attempt to quit. But the whole point here is that you should make it a part of their entire treatment plan, and then institute it when it's most appropriate for that particular individual. So why should we do this? Why should we address this? Well, it's probably the single most active use of our time and fun that we have in any kind of healthcare setting. We know very clearly that if a health care professional encourages a person to quit, it significantly increases their chance of quitting. And looking at surveys, we know that this is one of the few behavioral health interventions that people actually rate positively. So not only do your patients expect you to bring up cessation, but they are pleased and happy that you're doing it. I think this is because many -- almost every person that smokes wants to quit. But they just don't know how to bring it up to you. So you bringing it up, you know, makes it much easier for them to address it. And then from the flip side, I really feel that if you don't bring it up, and think about this from the patient's perspective. If you don't say anything about their smoking, that is tasked in their mind to continue to do it. So it's really incumbent upon all of us to discuss this subject. Now what do we talk about, what is the background for all this? Well, this document was put together in 2008. My understanding is they are working on an update. But this is a meta analysis of over 8,000 research projects that looks at best practices. So everything we're giving you today and everything I'll be talking about Monday is vetted and we know works. We know from this meta analysis that the very fact that you say something as a nonphysician clinician nearly doubles their chances of quitting. And then if you are a physician, it more than doubles their chances of quitting. So the fact that you just bring this up increases their chances of quitting. It's called the five As. So this is the treatment protocol that was devised for all health care professionals. So I'm just going to go through this very quickly and give you a basic idea of what is involved with each one of these. Don't get whetted to this. It's not necessarily that you actually follow this exactly. But it just gives you a -- okay. I see it that my audio's breaking up a bit. I'm not sure what to do. >> Sorry, y'all. Yeah, you are cutting in and out a little bit, but hopefully it should resolve itself soon. Just keep going and hopefully you don't have any more issues on the connectivity side. >> okay. Sorry about that. So we've got these five As. Ask, advise, assess, assist, and arrange. So I will go through each one of these and give you a basic idea of what to do with them. Again, what I was saying when people mentioned that the audio was going in and out is that don't whet yourself to this. It's just a suggestive framework. The first one here is that you have to know whether or not somebody smokes. So we need to ask this as clinicians of all patients. Do you smoke or use any other type of tobacco? Now that used to be what we would recommend, and that used to be very easy because there weren't all of these other products that are out there and all of these cigarettes and there's probably like 500 other things. You might want to just change it to do you smoke or use any type of nicotine? And that way you can get the whole, you know, get anything that they might be using. So once you know, then the data clearly shows that if someone is using, it does help for a health care professional to advise them to quit in a very clear, strong personalized way. And one of the simple things you can do is just to say it's important for your health that you quit smoking and I can help you. So that's a very, very simple way of quitting it. We also know that people in recovery are more likely to stay sober if they quit smoking. And we know that with many psychiatric diagnoses that people are more likely to stay stable if they quit smoking. So, this affects and this is tied into almost any diagnosis that anyone has. So this is just suggestive language here for you. Again, you're not whetted to this. But it's very important that people know why they should quit. So we tell people that they should quit, but we never tell them why. So I always recommend that you add to that, that the person that you tie into what their situation is, either behaviorally or medically about why it's good for them to quit. We'll talk about assessing readiness to quit in much more detail in a moment. Then you want to assess them with their quit attempt. So this will be whatever you are comfortable doing and whatever you have time -- if any of you are behavioral health therapists, then this will amount to the therapy that you do with your patient anyways. Most of the assisting, as you will see that I'll be talking about today is basic cognitive behavioral therapy. -- and here is where we look at in both the assess and assist where they are in the quitting process. So what you're going to do for someone who's not quite ready to quit is different from someone who is ready to quit and then what you're going to do with someone who has quit already. Arrange refers to the fact that this is not a one-time deal. It's not a one-time interaction with a patient. So we know that the more hits, the more times you discuss this with a patient, the more likely they are to quit and to stay quit. Now, this doesn't mean that you have to do all of these follow-ups. There are many different ways that we can arrange to help people follow up with an individual that does not necessarily entail you being that person. There are quit lines and there are many other supports we'll go through later on in the training that you can access to help with this part. However, again, I'm guessing that many of you or most of you are in a behavioral health setting. You're seeing these patients on a regular basis anyways. So you'll be able to incorporate this into their -- without any problem. So these are the stages we're going to talk about. And, again, I'm just going to go through these very quickly with you about what to do and what not. So someone who's not quite ready to quit, they are probably not really aware of the need to quit. So here is where education comes in and if you may need to take a bit of time to actually explain how it is impacting their help. People don't really have a very good reason to quit. So the focus here is finding motivation. Nobody does any kind of change, nobody makes any kind of behavioral change unless they are clearly motivated to do so. So that's what you want to focus on here. And not on creating a quitting plan. So that is in the next stage. So here is where you want to use motivational interviewing more than any of the other -- I know many of you have probably had motivational interviewing and training and I know that you know that clearly it takes days to do and that a lot of work to incorporate. I'm just going to touch upon some very, very basic -- fundamental issues that apply to cessation that we know work here. So just as a definition of motivational interviewing is, as you can see here, it's a way of eliciting a patient, a client, to change and by finding their own motivation for doing so. So, in other words, you want to guide the person. And this is very important. We end up as health care professionals, more or less, unintentionally hollering at our clients that they better stop smoking. Then you end up wagging your finger at them. If we do that, and, again, we do it with good intention. We end up turning into their mothers. It's like the mother hollering at the little kid for doing something bad. So we don't like to do that. We don't want to do that and what does the client do? They do exactly what a kid does. They resist. If we use motivational interviewing, we then are guiding them to tell us they want to change rather than us telling them they have to change. So this is about you asking such provocative questions and providing them with such powerful information that they make the internal decision to do this and then tell us they want to quit rather than us telling them they have to quit. So you really do want to avoid all of the finger wagging and nagging. And I'm sure you're all aware of this. But it's important to reaffirm that. And the benefit to using this approach, as I think all of you know, is that it really gets you away from that idea of noncompliance -- and establishes a real connection and collaboration between you and the patient and the client. When you collaborate, the goal here is to elicit change talk. So, again, this is getting the person to tell us they want to change. It makes change more enticing than the status quo, and to help them believe they can do it. As you all know, again, all of you in behavioral health all know that change pretty much only happens if the idea comes from the individual, not from you. So how do you elicit change talk? Well, I have these five bullet points here that are in the motivational interviewing literature. But I just want to focus on one because I did have several trainers years ago if you only have a couple of minutes, what do you focus on? -- change the way they deal with clients. And the one thing they said most importantly was open-ended questions. You want to ask questions that begin with the word "what" or "how." So if you have someone who really is not interested in quitting, you might want to ask them what would have to happen for you for you to consider quitting? That is better than saying, well, don't you know smoking is bad for you? And there's really no place to go with that conversation, unfortunately. So what and how, try to get in the habit now of using those two words to start almost all questions you have when you're talking about quitting. All right. So that's just, again, very, very briefly what you want to do if someone's not quite ready. If someone is ready, what you want to do is create a plan. The biggest reason why most people do not quit successfully is they really don't do anything to make any kind of change. If you talk to people about what kind of behavior change they made when they smoke, when they quit smoking, most people just look at you like you're crazy. It's very, very important that you focus on this idea of creating a quitting plan. I find it fascinating. We know that if we have psychiatric problems, we have to go to a counselor. We have alcohol problems, we go to AA. Et cetera, et cetera. It seems that in our culture people think they can just make themselves quit smoking by somehow willing it to happen. That doesn't work. So this is where you really want to create a plan. And I'm going to go through some key issues here in creating that plan. You need to know what the person's tobacco use history was, how much they smoked, when they started, when they quit, what's happened when they've quit in the past, if they've never quit, what -- the reason they've never tried. Discuss key issues. So you want to know what are those things that are keeping them smoking? You know, what are the issues that are happening in their life? What do they think will happen if they quit? What negative consequences do they think? And most smokers do think something bad is going to happen if they quit. And that's what's keeping them from quitting. And then you really want to focus here, and I can't emphasize this enough, the practical problem-solving and skills training. So, what you're going to see in a moment is that most people smoke in very specific situations that they have connected the smoking after years and years and years of doing it in their situation. And they literally don't know what else to do in those situations other than smoke. So that is an extremely important part of what you can do in helping someone be successful is to teach them coping strategies to deal with those situations without wanting a cigarette. And then finally it's very important to get social support either from you and their family, friends, et cetera, or really encouraging them to create a support system if you're in a behavioral health setting with each other. As we said, you want to assess their readiness to quit and then all this tobacco use history that we just talked about. Look at their motivation and their confidence to quit. So, what is the reason they want to quit? And make that as clear as you possibly can. And then really look at their confidence to quit. Now, there's a very simple way to increase somebody's confidence. Ask them what event, what thing have they done in their life that they are most proud of. And so let's say they say they paid their way through school or they raised three kids or they climbed a mountain. Whatever they say your next statement is if you can do that, you can quit smoking. Now I know that may seem very simplistic, but I've seen it work with hundreds of people. It really gets them to think about this in a whole different way. You want them to set a quit day. So think about this like breaking up with somebody. You can't sort of break up. You just have to do it on a specific day. You can't taper off of somebody. You can't say I hate you, I never want to see you again, you make me sick. However, let's date five days this week, four days next week and three days the week after that and let's break up. I think it's very important no matter what you're doing and how you're doing this, at some point that there would be a specific quit day where they say good-bye to the cigarettes and just move on. Then you really want to look at all those routines and situations that they associate with tobacco use. So this can be very specific behavioral situations like drinking coffee or be on the phone or, you know, being BORED or stressed. Those feelings could elicit an automatic trigger to smoking. So these are all of those situations that the individual has connected to smoking, so much so, that just doing that triggers them to want a cigarette, regardless of whether or not they have any nicotine in their system or they're in withdrawal or not in withdrawal. So it's very important for us to learn what those are for each individual clients and then teach them what to do in that situation so that they are not triggered to one cigarette, so that they can cope with those situations. And I think this is probably the biggest help that you can have with your clients is to really go into depth about what this habitual unconscious triggers are for each individual patient and then help them learn how to cope. Now, one of the biggest triggers for almost all smokers is stress. Many people are going to tell you that they can't function without cigarettes because it gets rid of all my stress or I can't relax or some version of those two things. So, you really do have to teach people how to deal with stress because in most cases your clients have not dealt with stress because they've been smoking. The biggest issue here, and this could probably take about half an hour of time for me to go into it, but I just want to point out one thing. When people smoke, they are in withdrawal half the time -- half the day. So they're taking a hit on a cigarette, they're raising their dopamine levels very, very high, they feel great. And then as soon as they stop smoking that cigarette, all those levels begin to drop and drop and drop and drop until they're in withdrawal. And with withdrawal is irritability, restlessness, impatience, all those really negative feels. So what does the smoker do when they're in withdrawal? They smoke another cigarette. So what happens is if you think about this, what does stress feel like? It's irritability, breathlessness and impatience. When they smoke another cigarette and they relieve withdrawal, they feel better. But since withdrawal and stress feel the same, they mix up getting rid of withdrawal with getting rid of stress. So after doing this for so many years. >> They begin to equate the two things. Now that's just again a very basic idea about what's happening. There are many other things that are going on with the individual. But the fact of the matter is the bottom line is all the research shows that smoking does not get rid of stress, smoking causes stress. But given that, the average smoker doesn't really know how to deal with it without smoking. So it's really important that you take some time to work with each client and teach them how to deal with stress. So here are some suggestions on this slide. And by the way you are going to get all these slides so you'll be able to refer to -- when we talk about coping strategies, so all those different situations I just mentioned. The word coping is either positive or behavioral. And you either do it before a person gets into a situation to encourage it from happening or teach them how to do things right in the situation so that they can deal with thoughts that do occur. So you either want to change how you think or change what you do in order to be able to deal with this particular situation without having a cigarette. And the slides that are on the site do go into many specifics about what you can do in certain situations, which, unfortunately, we don't have the time to do today. I do want you to think about this. All our clients think in terms of only. The only thing I can do if -- the only way my car will start in the morning is if I have a cigarette in my mouth. The only way I can do something after dinner is to smoke. So they think in terms of only. We need to really think in terms of alternatives. There always, always, always, is something the client can think or do in any of the situations other than smoke. They just don't know it. So that's our role here is to help them with coming up with a technique. And there's no bad technique. There's no bad coping suggestions as long as it works for the person, it doesn't hurt them, it's cool. So when you are looking at somebody or working with somebody to help them learn to cope, first ask them what they think they can do, and then if they can't think of anything, then you can provide them with some -- it's interesting when I do this, I try to give people a couple choices because you really don't know what would work in one person's situation versus another. And it's very important to make sure that they are appropriate to their lifestyle. There are many things that people probably, you know, maybe can't do just simply because of their situation in their life. You want to talk about medication counseling. So as we progress through the quitting plan, you want to talk about slips versus a relapse. If somebody has a slip which means one cigarette in a very isolated situation, you don't want them to panic. You really want to help them work on, you know, on what they can do in that situation should they encounter it again. I really suggest you try to follow up with people maybe a week or so after they quit, and then as many other times as you possibly can, and then congratulate the situation. It's very, very important that you tell people how well they're doing. I have actually had grown men cry in front of me when I've told them I'm very proud of them and what they're doing in this process because it is a very big deal for very many people. Put it in your own words but congratulate them. All right. So hopefully the person has quit, and now they're trying to stay quit. So this, for those of you who are in substance abuse work, you know it's all about preventing relapse. So you really want to look at increasing their coping strategies, looking at trigger situation. It's interesting the first couple weeks somebody has quit, they are able to cope with most of the things that happen. But then I always see in the third or fourth or fifth week something happens out of the blue and that they weren't expecting and they're having issues trying to -- and you want to try to anticipate as much as possible. So the mantra here is anticipate, plan, and rehearse. So anticipate what problems -- what situations might be a problem, create a plan to deal with them, and then rehearse it whether the person does it in their mind's eye or actually rehearses it with you. And then try -- and that then may prevent these relapses from occurring. You also want to look here at medication adherence. Are they using it correctly? If you're two or three months out from the quit date, what to do in terms of terminating the medication use. And we'll talk about all of that on Monday. So it's important to keep this going and realize that, as I said at the very beginning, this is not a one-time intervention. So if you can't do this, you might have a group at your setting where they can go to -- much like an AA meeting, there are quit lines and we'll talk about those in a moment where you can refer people to, to get support, free support. The cancer society, the lung association in your area may have groups. So look to see what's available in your particular area that you can refer people to or look to see what you can create within your agency that will allow them to get support through this whole process. Now, if you can't do all five of these steps, then there is a shorter protocol. Ask, advise, refer. So again ask every client about tobacco use, advise those who want to quit in a very clear strong personalized way, and then refer them to other resources to actually create the -- and one of the strongest places you can refer them -- every single state in the country has a quit line and it is free to all the residents in that state. Now given that, there is one national phone number, 1-800-quitnow. If you call from Florida, that will put you in Florida's quit line. If you call from California, that will put you in California's quit line. It has the technology to put you into the local state's quit line. These are funded, in many cases, through the tobacco cessation money in some states. There is a additional money. And unfortunately a lot of variety here as to what those services are. But we do know bottom line is every state at least has the basic services that I will be describing to you. Many, many state quit lines also have specific trainings for their counselors in behavioral health so you have to check your state to find out exactly what is available for the people in your particular state. So if we look at the question what are tobacco quit lines? They provide cessation counseling, as I said, free of charge to everybody in the country via telephone. So you will have the quit line services available to you. The highly trained specialists, almost every quit line, the clinicians are master level individuals. They're either nurses or counselors like yourself who have had special training in this area. Most states give personalized -- they make the call to the patient, to the client, on a regularly scheduled basis. In some states, I know I'm in Pittsburg, so Pennsylvania occasionally has money to give therapy. So either the nicotine patch or the Lozenge is free of charge. Medicaid programs, medical assistance programs now are providing full coverage of the medication. Again, see what your particular state has. And we do see a very significant success rate for patients who have used the quit line, followed through with it, and use the medication for cessation. So I can't recommend these enough. Now, it's interesting to note, too, that there are probably I think now 28 to 30 different languages available to people -- you should be able to find someone who speaks the language of that particular client. It's individualized counseling. So they do exactly what I'm just suggesting that you do with patients as they create a specific tailored individualized quitting plan. Some of them refer to local programs. So there is a lot of variety here in what's available for each. I also want to point out that there are some states programs for individuals who are -- there are a few -- starting to look at creating these different niches, these different types of counseling. [ Inaudible ] groups of individuals who need the specific information. So, again, I can't encourage you enough to find out what's available from your particular state and from your particular quit line. So I just want to end this part by the rah rah rah speech that it's very important that we all do this. I know from my own work and from all the work I've done around the country in all these years that the more we get involved and the more that patients hear this message that it's important to quit the more likely they are to quit. So if your dentist is mentioning this and your doctor is mentioning this, and, you know, your physical therapist or your respiratory therapist, whoever, that the synergy of all of that increases the person's chances of quitting. And I think it's a very important concept that we don't say anything, giving people the go-ahead to continue to smoke. I've heard this from so many patients and they say, frank, why should I quit? My doctor never said a word to me or my dentist, she never brought up anything about it. They really do -- even though most smokers tell us they want to quit, there is that little voice in the back of their head that is desperately trying to find a rationale to continue to smoke. And so if we don't say anything, that, unfortunately, gives them the go-ahead to do this. So again very brief overview of all of this. If you have any questions, we've got plenty of time now to go through this. On Monday we will go through all seven of the FDA approved medications that can be used to help people in conjunction with a behavior change here. And this is my contact information. So please feel free to contact me if you have any general questions or any specific questions about a patient. I will be happy to work with you. Or even if you need help setting up a program in your particular -- I will be happy to work with you on that. All right. So let's open it up to questions. >> Wonderful. Thank you so much for sharing your expertise, frank. With that we are now ready to take questions from the audience. As a reminder you can type questions into the Q&A panel or simply use the chat box. We're just going to give everybody a few minutes to type in their questions. >> I have a question. Did we solve the audio problem? >> we are still kind of cutting in and out at times, frank. But I think for the most part it was okay. Apologies to anyone who experienced some difficulties and we will make sure to keep this in mind and amend it during our part two webinar on Monday. So thanks. And in the interest of time we wanted to keep going. But thanks, everyone, for understanding these technical WOES that often come up during webinars. I think we can start with this question. >> we have a question here. Can you speak about best practices around pregnant women using nicotine or placement therapy? >> okay. Well, yes, there's a lot of issue with that. In the clinical practice guidelines, they only talk about what has been shown to be effective and safe through research. So as you can imagine, there's been very little research done with pregnant women because, obviously, most pregnant women are not going to put themselves in a research project. So the clinical practice guidelines really don't say much this. And pretty much steer clear of using any of the medications. However, we know very clearly what the negative health effects are on the fetus from smoking. That occurs all primarily from the lack of oxygen to the fetus because there is so much carbon monoxide in the cigarette. So we know very clearly that smoking is negatively affecting the fetus and the mother. So it is very important that they quit. Given that the guidelines say to use behavioral therapy almost exclusively. However, I'm comfortable saying that if somebody wanted to use the patch or the gum or the LOzenge, so one of the over-the-counter product that they use it to intermittently for a few days of the first week in order to get over that hump of the withdrawal and then get off of it as fast as they can. Given that, I would recommend to all of you that if you have a pregnant woman that wants to quit that she go to her ObGyn and discuss it with the doctor and have the doctor prescribe any of the products even if they're over the counter. That way there's no liability issue. Any of these products used in the short term are much, much, much, much, much, much safer than continuing to smoke. I hope that's not too vague, but again the data is lacking simply because they haven't been able to do much research. >> thank you so much, frank. We have another question here. It's what are some ways outpatient settings and behavioral health clinics can reduce encouragement of smoking breaks for clients for use of cigarettes as an incentive? >> that's a very good question. And that's kind of like the dirty little secret that we have had in this profession. I worked in a psychiatric hospital. I worked in an outpatient clinic. I worked in a day hospital. And we used cigarettes to get people to go to group. We used cigarettes to get people to take their medication. So we really need to stop doing that first of all and make all of our facilities smoke-free. So the smoking cessation leadership center, there are some people on the call from there. They have plenty of information. And so does the national council on helping your facility go smoke-free. So that's the number one step. And number two is to look at what other incentives can you give to your patients for doing these things? So going to group, taking their medication. You know, if you're in a facility where people are, you know, on a locked unit or on a unit, you can create fresh air breaks instead of smoking breaks. Many people have created -- I love this -- instead of having their smoking areas outside of their building, they've created gardens and they've made it a positive space where people can get fresh air and they can relax, they can contemplate, they can meditate. So there are many, you know, many things like that that we can do. But I think the first step is to really look at making your facility smoke-free and then working with your clients as much as you possibly can to help them quit smoking, and then it doesn't become an issue because the people are not smoking. >> Those are all wonderful tips, frank. We have a question here about quit lines. How are the quit rates actually calculated? Is it self-reported of those who complete the program only? >> unfortunately yes because there's really no way to do any kind of biochemical follow-up. So as far as I know, and we have to contact the quit line council for this. But it's self-report. So you have to take that into consideration when you look at these quit rates. But even if there is some, you know, discrepancy there, fudging, whatever the word you want to use, it's still way better than quitting what we know to be the quit rates when someone just does it on their own. So don't let that particular issue stop you from referring to a quit line. We know very clearly that there is significant increases in quit rates when people do use constantly. Wherever they get it. >> Thank you, frank. We have a lot of interesting questions pouring in. Thank you, audience members. We have a question about cancer survivors. What is your experience with working with survivors of lung cancer and smoking cessation? Are there any differences in counseling to should take place even though they have already experienced lung cancer treatment? >> I think the biggest issue there and the biggest barrier is guilt. These individuals know by and large that they caused their own cancer from smoking. And in many cases the guilt overwhelms them and ends up getting or prompting them to go back to smoking because they just figure what the heck. You know, I did this, I'm a bad person, I don't deserve to have a good life. Any kind of version of that kind of negative thinking. That I see much more often with individuals with lung cancer. And I did a lot of work with COPD patients and they kind of have the same attitude. So you really do have to work with them about that and to make sure that they have a positive attitude about all of this and to move past it, to help them get past that whole I caused this, it's my fault, I'm bad. >> Thank you, frank. We have a couple of questions on dosaging and different medication. This is about double patching. Can you talk about double patching? I know it's discussed in training environments but it's very difficult to get prescribers to prescribe outside instructions on the box. >> we'll talk a lot about that on Monday, but I'll just mention it very quickly. Yes, that can be done. It's very, very, very difficult for anybody who smokes to get too much nicotine from any of these products because they all have less nicotine in them than what they're getting from smoking during the day. And it's not delivered as fast. So there is very, very, very little chance that they can become addicted to any of these medications as they would with smoking. Again I'll go into detail on that on Monday. But I've used double patches. I've used patches and gum and LOSANGE. So that would be my thing, to use the 20-milligram patch and then to layer on, um, gum or LOSANGE PRN to deal with situations. We talk about combo therapy. That's really what most people are doing now. I would only use two patches on somebody who is smoking like two or three or four packs of cigarettes a day. And in that case I've seen research where they've tried to TITRATE up to the level of the high levels of smoking by using the patches in the first week or two. But I would only do that under the supervision of a physician, and I'd be very careful with that, just given the fact that they are getting a much higher level of nicotine if you use two patches. And you're increasing the chances of sleep disturbances by doing that if they keep them on all day and of skin irritation because you now have two sites instead of one to deal with. But, yeah, it's been shown to be effective. I know people have done research on it. As long as you're monitoring it, I have no issue with it. >> Thank you, frank. We have another question about the nicotine gum. How do you assist someone who quits smoking but now has trouble with discontinuing use of the gum? >> it is that psychological totally. So what you want to do is get them on a specific number a day. So let's say you get them to use six pieces a day and space them evenly out through the day. They do that for one week. Then they do five pieces a day for one week. Then they do four pieces a day for one week until they are off of it completely. Again we will talk about this on Monday. That is not a physical addiction to the nicotine. That is completely and totally psychological. They are just afraid to get off the nicotine because they think something bad is going to happen to them. But that's the way to do it to taper it off very slowly. >> Thank you, frank. We have another question on a sub population. Do you have any advice or resources for smoking cessation in adolescents and youth ages 11-17? >> again, there hasn't been much research on that. I have done some programming on that around the country. I did a program years ago in New York. I don't know if that's still being used. Here is the issue with that. If you have to look at what these kids are getting out of smoking, you know, what's the issue, why are they doing it? They don't think they're addicted or that they can become addicted. So that's the other thing you really want to focus on. With adults I really don't use that word too much with adolescents. It is all about the fact that they don't think they can become addicted so you really need to educate them that they are going to become addicted, that that's the nature of nicotine and putting it in your body, your body just keeps demanding more and more and more of it. And the other thing is I've always focused on with adolescents is this idea of control. They don't want anybody telling them what to do. So you need to really focus that the reason they're smoking is not because they want smoke, it's not because their friends are smoking. It's because the tobacco companies want them to smoke. So they're being manipulated by these tobacco companies to replace the smokers who died. I think the most effective thing I tell kids is you're just a body. 3,000 people die every day in this country from smoking. So all those companies, they just need another body. They're recruiting you, they're manipulating you, they're using you. That seems to work, you know, better than anything else. And I certainly wouldn't talk about health because most kids could care less about that or, you know, they're not even thinking about it. So there's no use in telling them that it's going to give you a heart attack or it's going to cause lung cancer because they're not really concerned about that. As far as that goes, there is a website called become an EX. That is ex-smoker. That is aimed at teens. Become an EX. And there should be a lot of good information there. >> Thank you for that research, frank. So it looks like we have time for one more question. >> Okay. >> Thank you so much for submitting questions. But for questions that we did not get to today, we will be posting answers to your question on our website. The last question is do you know of research regarding the use of peer counseling for smoking cessation? Would be a person with whom the client can identify and has successfully quit one group that is tier based is nicotine anonymous but this does not appear in the guidelines because of lack of research. Nicotine anonymous is a 12-step program similar to AA. >> okay. My experience, and I'm not putting nicotine anonymous down, but over the years I don't really think there is much evidence to know that it works for cessation of tobacco. It works beautifully for alcohol. And I've got friends in the program so I know that. I'm not questioning that. But I don't know that there is much data available for nicotine anonymous. So that's why it's not included in the guidelines. Now as far as peer counseling goes, that is included. We do have a lot of data to show that works. If you go to the smoking cessation leadership center or the arts for change site, there is a training that I created for peers that is recorded on there. So you can access that and you can use that to train your peers in your setting. So I would encourage you to do that. There is no such thing as too much support and too much help. So, I always say this to everybody I'm training. You just might be the person this particular patient will pay attention to. So it's very important that all of us from peers to psychiatrists and everybody in between that we get out this message to our clients and that we are able to talk to them about this. So, yes, go to the smoking cessation leadership center. Both of those sites have a lot of information on peers and there is actually a training there for them. >> That's all the time we have today for questions. Let's give a virtual round of applause to frank. We are so greatful for his willingness to share his knowledge with everyone today. >> Thank you, everybody. And I hope to see you at the next training. And this is -- that is the website for arts for change on that one slide. >> and as a reminder, we will be continuing this webinar series on Monday March 9th from 2 to 3:00 p.m. eastern. Join us for part two of assisting clients with quitting, how to talk the talk for successful tobacco cessation by reserving your spot on screen and in the chat box. Let me again thank our speaker for sharing such great information. Also thank you to all of you for joining us today on our webinar. Before you exit the webinar just a quick reminder to please take a few moments to fill out the survey. That should pop up on your screen. This gives us an opportunity to learn about what your needs are and identify how we can further improve our webinars. I also want to remind everyone that the recording will be available on our website within two business days. You can access the recording and slides. Thank you and have a great rest of your day. >> thanks all.