Toolkit for delivering the 5A’s and 5R’s brief tobacco interventions to TB patients in primary care

Toolkit for delivering the 5A’s and 5R’s brief tobacco interventions to TB patients in primary care

WHO Library Cataloguing-in-Publication Data Toolkit for delivering the 5A’s and 5R’s brief tobacco interventions to TB patients in primary care. 1.Smoking – adverse effects. 2.Smoking Cessation - methods. 3.Tuberculosis, Pulmonary - complications. 4.Tuberculosis, Pulmonary – prevention and control. 5.Tobacco Use Disorder. 6.Practice Guideline. 7.Delivery of Health Care. I.World Health Organization. ISBN 978 92 4 150694 6 (print) ISBN 978 92 4 069260 2 (ePUB) © World Health Organization 2014 All rights reserved. Publications of the World Health Organization are available on the WHO website (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int). Requests for permission to reproduce or translate WHO publications –whether for sale or for non-commercial distribution– should be addressed to WHO Press through the WHO website (www.who.int/about/licensing/copyright_form/en/index.html). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. 2

(NLM classification: WM 290)

TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

Contents Introduction ...........................................................................................................................................................................4 I. Tuberculosis and tobacco use: A deadly combination ............................................................................................5 II. The unique role of the TB care provider in tobacco control ..........................................................................6 III. Basics of tobacco use and tobacco dependence ...........................................................................................7 i. The impact of tobacco use on tobacco users and others.............................................................................7 ii. Benefits of quitting ......................................................................................................................................8 iii.Three challenges to quitting.......................................................................................................................10 IV. The 5A’s model to help patients ready to quit .............................................................................................12 V. The 5R’s model to increase motivation to quit. ...........................................................................................14 VI. The 5A’s to avoid exposure to secondhand smoke ......................................................................................16 References and resources ...............................................................................................................................................17 Acknowledgements ...........................................................................................................................................................17

CO N T E N T S TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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Introduction This toolkit was developed based on WHO Capacity Building Training Package 4 entitled “Strengthening health systems for treating tobacco dependence in primary care” and A WHO/The Union Monograph on TB and tobacco control: joining efforts to control two related global epidemics. Its target audience are TB care providers. It aims to serve as a quick reference guide to help TB care providers deliver brief tobacco interventions as part of their routine practice in primary care. The content of this toolkit includes: 1. Tuberculosis and tobacco use: a deadly combination; 2. The unique role of the TB care provider in tobacco control; 3. Basics of tobacco use and tobacco dependence; 4. The 5A’s model to help patients ready to quit; 5. The 5R’s model to increase motivation to quit; 6. The 5A’s to avoid exposure to secondhand smoke.

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IN TR O D U CTIO N TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

I. Tuberculosis and tobacco use: A deadly combination There are confirmed associations between tobacco use and tuberculosis (TB) outcomes, in that active and passive exposure to tobacco smoke is significantly associated with TB infection, disease, recurrent TB and TB mortality (Table 1). It was estimated that 23% of TB cases in 22 high-burden TB countries could be attributable to active smoking. Table 1: Associations between tobacco use and tuberculosis Exposure to tobacco Active Outcome TB infection TB disease Recurrent TB TB-related death Passive TB infection TB disease Range of odds ratios 1.03-3.20 1.01-6.30 2.50-3.00 1.10-1.60 1.03-3.20 1.60-9.30

Therefore, opportunities must be created within the health care system to support every TB patient who is a smoker to quit smoking; every TB patient who is not a smoker to avoid exposure to secondhand smoke. By doing so your patients can significantly improve their TB treatment outcomes and avoid the likelihood of recurrent TB and 1 in 5 TB-related deaths.

I. T U BE R CU L O SIS AN D T O BACCO U SE : A D E AD LY CO MBIN AT IO N TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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II. The unique role

of the TB care provider in tobacco control

Health professionals have several roles to play in comprehensive tobacco control efforts, including role model, clinician, educator, scientist, leader, opinion-builder, and alliance builder. As a TB care provider, you should at least: – Serves as tobacco-free role models for the TB patients; – Address tobacco dependence as part of your standard of care practice; – Assess exposure to secondhand smoke and provide information about avoiding all exposure. TB care providers are in the unique position in helping smokers. Patients undergoing TB treatment under the directly observed therapy, short-course (DOTS) are typically in regular contact with the TB care providers for a minimum of six months. At every encounter with their clients or patients, TB care providers have a unique opportunity to deliver tobacco cessation interventions. By the end of 2007 DOTS programme was being applied in more than 180 countries covering 94% of the world’s population. If all TB care providers routinely ask about tobacco smoking and advise smokers to stop, they have the potential to reach more than one million smokers in a single year worldwide through the DOTS programme (About 5.8 million new and relapse TB cases notified under DOTS in 2011; Even if only 20% of them smoke tobacco, the DOTS programme could reach more than one million smokers per year). Another wide-reach Stop TB Strategy is the Practical Approach to Lung Health (PAL), which has the potential to reach 20%-35% of patients in primary care settings. Helping TB patients quit smoking as part of TB care providers’ routine practice takes them only three to five minutes and is feasible, effective and efficient. TB care providers can at least trigger 40% of cases to make a quit attempt; and help up to 67% of those receiving brief advice quit successfully at the end of TB treatment. The algorithm below can guide you to deliver the 5A’s and 5R’s brief tobacco interventions to TB patients in primary care (Figure 1). Figure 1. Algorithm for delivering brief tobacco interventions Ask: do you use tobacco? Section IV

YES

NO

Advise in a clear, strong and personalized manner. Section IV

Ask: does anyone else smoke around you? Section VI YES Help avoid exposure to second-hand smoke. Section VI NO Encourage continued abstinence.

Assess: if the patient is ready to quit? Section IV YES Assist and Arrange. Section IV NO Promote motivation to quit (5Rs). Section V

All TB care providers should also promote smoke-free policies, particularly where TB services are delivered so that your patients will not be exposed to secondhand smoke in your health facilities. By having a smoke free facility, you can encourage your patients to live in a smoke free home and work in a smoke free workplace, which will help them avoid exposure to secondhand smoke. 6 II. TH E U N IQ U E ROLE OF THE TB CARE PROVIDER IN TOBA CCO CO N T R O L TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

III. Basics of tobacco use and tobacco dependence In order to assist TB patients in quitting more effectively, every TB care provider should have some basic knowledge of tobacco use and tobacco dependence – such as the impact of tobacco use; the benefits of quitting tobacco use; and why people smoke and do not quit. The following information on the risk of tobacco use, the benefits of quitting, the three challenges in quitting tobacco and effective coping skills will help you deliver brief tobacco interventions.

i. THE IMPACT OF TOBACCO USE ON TOBACCO USERS AND OTHERS For those TB patients who still do not feel that they should quit smoking it is important to go over the risks that are involved. Tobacco use will have both health and non-health impacts on tobacco users and others.

HEALTH IMPACT This includes health risks to tobacco users and their family. Tobacco kills up to half of its users because tobacco products are made of extremely toxic materials. Tobacco smoke contains more than 7000 chemicals, of which at least 250 are known to be harmful and at least 69 are known to cause cancer. All tobacco products are harmful. Tobacco smoking can damage every part of the body, causing many actual medical conditions such as shortness of breath, exacerbation of asthma and respiratory infections as well as many chronic diseases including heart disease, strokes, cancer, chronic respiratory diseases and TB. As a smoker with TB, the combination of the two greatly increases TB patients’ health risks: • Smoking increases the severity of their TB symptoms. Smokers with TB are more likely to have: – Cough – Dyspnea – Cavitary lesions in the lung – Positive sputum culture (this means that smokers are more likely to spread TB as well) – Drug resistance • Smoking will significantly increase their probability of having recurrent TB • Smoking greatly increases their chance of dying from TB Smoking puts the smoker’s family at risk. Secondhand smoke exposure increases the risks of having the following diseases: Diseases in children − − − − sudden infant death syndrome; acute respiratory illnesses; middle ear disease; chronic respiratory symptoms. Diseases in adults − − − − coronary heart disease; nasal irritation; lung cancer; reproductive effects in women (low birth weight).

III. BASICS O F T O BACCO U SE AN D T O BACCO D E PE N D E N CE TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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Exposure to secondhand smoke will also significantly increase the risks of having TB infection and TB disease for TB patients’ family. You will need to be prepared to help patients debunk misconceptions about health risks of smoking. Many smokers, especially those in developing countries, do not completely understand the dangers of tobacco smoking due to tobacco companies’ misleading data that distort the true things about smoking.

ECONOMIC IMPACT OF TOBACCO USE Tobacco smoking takes away not just the smoker’s health but wealth. It is estimated that 5-15% of a smoker’s disposable income is spent on tobacco, which could be an enormous economic burden on them and their family. You can use the cost calculator below to help patients find out how much money they have spent on cigarettes. The smoking cost calculator Number of packs you smoke a year* X Number of years you have smoked X The average cigarette pack price = How much you have spent on cigarettes during your lifetime

X

X

=

*: For day to year conversion, see below table 1 pack a day 365 packs a year 1 ½ packs a day 548 packs a year 2 packs a day 730 packs a year 2 ½ packs a day 913 packs a year 3 packs a day 1095 packs a year

Tobacco smoking causes an acknowledgeable amount of suffering for families and individuals associating with smokers. This suffering manifests itself in the form of diminished quality of life, death, and financial burden.

SOCIAL CONSEQUENCES OF TOBACCO USE Smoking affects social interaction and relationships negatively. In most cultures, people see smokers negatively. There is a stigma attached to smoking (for example, people may think the smoker is smelly, disgusting/dirty, unhealthy…). As a smoker, their personal relationships may be affected because many people don’t consider being in a relationship with a smoker. As a smoker, their children are more likely to smoke and to be heavier smokers at young ages.

ii. BENEFITS OF QUITTING You can explain to patients about the benefits of quitting in order to motivate them to make a quit attempt.

HEALTH BENEFITS Helping your patients quit is the best thing that you can do to improve their health. There are immediate and long term health benefits of quitting for all smokers. You can extend the patient’s life up to 10 years by quitting. It is important to help your patients quit smoking as soon as possible so they can achieve these beneficial health changes and can live a longer and healthier life. (See Table 2).

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III. BA S IC S O F TOBACCO USE AND TOBACCO DEPENDENCE TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

Table 2. Fact sheet: Health benefits of smoking cessation Fact sheet: Health benefits of smoking cessation A. There are immediate and long term health benefits of quitting for all smokers. Time since quitting Within 20 minutes 12 hours 2-12 weeks 1-9 months 1 year 5 years 10 years 15 years Beneficial health changes that take place Your heart rate and blood pressure drop. The carbon monoxide level in your blood drops to normal. Your circulation improves and your lung function increases. Coughing and shortness of breath decrease. Your risk of coronary heart disease is about half that of a smoker. Your stroke risk is reduced to that of a non-smoker 5 to 15 years after quitting. Your risk of lung cancer falls to about half that of a smoker and your risk of cancer of the mouth, throat, esophagus, bladder, cervix, and pancreas decreases. The risk of coronary heart disease is that of a non-smoker’s.

B. Benefits for all ages and people who have already developed smoking-related health problems. They can still benefit from quitting. Time of quitting smoking At about 30 At about 40 At about 50 At about 60 After the onset of lifethreatening disease Benefits in comparison with those who continued Gain almost 10 years of life expectancy Gain 9 years of life expectancy Gain 6 years of life expectancy Gain 3 years of life expectancy Rapid benefit, people who quit smoking after having a heart attack reduce their chances of having another heart attack by 50 per cent.

C. Quitting smoking decreases the excess risk of many diseases related to second-hand smoke in children, such as respiratory diseases (e.g., asthma) and ear infections. D. Quitting smoking reduces the chances of impotence, having difficulty getting pregnant, having premature births, babies with low birth weights, and miscarriage.

As a TB patient, quitting smoking can help: • Improve their treatment outcomes • Reduce their chance of having recurrent TB and dying from TB.

III. BASICS O F T O BACCO U SE AN D T O BACCO D E PE N D E N CE TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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ECONOMIC BENEFITS Quitting also has very clear and tangible financial benefits to smokers. You can use the quit & save exercise to help patients understand how much money they can save if they quit. Quit & Save How much money can you save if you quit? Total money spent on tobacco per day Amount of money spent per month Amount of money spent per year Amount of money spent in 10 years What you can buy with the money saved?

SOCIAL BENEFITS After quitting, patients will feel less isolated - quitting means they can go anywhere, not just where they can smoke. They will improve their relationships with their family, friends and employers. They will be more productive - they don’t have to keep stopping what they are doing to have a smoke. They will be able to expand their social interactions. When patients quit smoking, their children become less likely to start smoking and more likely to quit if they already smoke.

iii. THREE CHALLENGES TO QUITTING In order for you to assist smokers in planning and making a quit attempt, it is important that you familiarize yourself with the common challenges and barriers to quitting and effective coping strategies and skills. Different people have different reasons why they smoke and why they don’t quit. Their reasons are typically classified into three categories: physical addiction, behavioral and social connections, and psychological or emotional connections.

PHYSICAL ADDICTION Nicotine, an addictive chemical in tobacco products, affects the dopamine systems in the smoker’s brain and increases the number of nicotinic receptors in the brain. As a smoker, their brain and body become used to functioning on certain level of nicotine. If they stop smoking, their nicotine level will drop dramatically one or two hours after the last cigarette, which will cause them to crave nicotine (cigarettes) and have withdrawal symptoms.

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III. BA S IC S O F TOBACCO USE AND TOBACCO DEPENDENCE TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

Nicotine withdrawal symptoms that may occur from suddenly stopping the use of tobacco such as headaches, coughing, cravings, increased appetite or weight gain, mood changes (sadness, irritability, frustration, or anger), restless, decreased heart rate, difficulty concentrating, influenza–like symptoms and insomnia, can be a major barrier against attempting to quit or staying quit. The good news is that these symptoms are normally temporary (2-4 weeks) and not all people will experience withdrawal symptoms. There are also effective methods available to help smokers overcome them. There are two ways to deal with nicotine withdrawal symptoms: cognitive-behavioral therapies and pharmacological/medical therapies (nicotine replacement therapies, bupropion and varenicline) (Please refer to “A guide for tuberculosis patients to quit smoking” for details).

EMOTIONAL/PSYCHOLOGICAL CONNECTIONS Smokers link cigarettes and smoking with certain emotions, thoughts, and beliefs via the process of withdrawal and “operant conditioning”. Part of quitting involves breaking those subconscious connections. It is important to work with your patients to find out the links between smoking and their feelings and beliefs that smokers form and to help them debunk negative beliefs of smoking and quitting (for example, “Smoking helps me relax”, “Smoking isn’t really harmful”). You can suggest patients create positive selftalks based on the benefits of quitting, such as “quitting can help improve my TB treatment outcomes”, “quitting can reduce my chance of having recurrent TB”, to help them break the connections between quitting and negative beliefs.

BEHAVIORAL AND SOCIAL CONNECTIONS Smoking is a habit – an addictive habit. It is so intimately tied to the smoker’s everyday activities. To quit smoking, the smoker needs to break these connections that have formed the habit. You should work with your patients to find out what behavior or action has been associated with smoking and identify effective strategies or activities to break the connections (Please refer to “A guide for tuberculosis patients to quit smoking” for details). It is important to remember that these three types of challenges are not necessarily separate obstacles. Success in dealing with challenges of one category can help patients deal with challenges from the other categories as well.

III. BASICS O F T O BACCO U SE AN D T O BACCO D E PE N D E N CE TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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IV. The 5A’s model

to help patients ready to quit

The 5As (Ask, Advise, Assess, Assist, Arrange) summarize all the activities that a TB care provider can do to help a tobacco user within 3−5 minutes in a primary care setting. This model can guide you through the right process to talk to patients who are ready to quit about tobacco use and deliver advice. Please find below action and strategies for implementing each of the 5As (Table 3). Table 3. The 5A’s brief tobacco interventions for TB patients ready to quit 5A’s Ask Systematically identify all tobacco users at every visit. Action • Ask ALL of your TB patients at encounter if they use tobacco and register the information in the patient’s TB Treatment Card. • Make it part of your routine. Strategies for implementation • Tobacco use should be asked about in a friendly way – it is not an accusation. • Keep it simple, some sample questions may include: – “Do you smoke cigarettes?” – “Do you use any tobacco products?” • Tobacco use status should be included in TB treatment card. Countries should consider including the information on tobacco use in TB treatment card. Advise Persuade all tobacco users that they need to quit • Urge every tobacco user to quit Advice should be: in a clear, strong and personalized • Clear – “It is important that you quit now, and I can help you.” “Cutting manner. down while you are having TB is not enough.” “Occasional or light smoking is still dangerous.” • Strong – “As your doctor, I need you to know that quitting smoking is the most important thing you can do to protect your health now and in the future. We are here to help you.” • Personalized – Tie tobacco use to: − Demographics: For example, women may be more likely to be interested in the effects of smoking on fertility than men. − Health concerns: TB patients need to hear about the effect of smoking on TB treatment outcomes, the possbility of having recurrent TB and TB-related deaths. “Quitting may dramatically improve the lasing success of your TB treatment.” − Social factors: People with young children may be motivated by information on the effects of second-hand smoke, while a person struggling with money may want to consider the financial costs of smoking. “Quitting smoking may reduce the chance of TB infection your child has.” In some cases, how to tailor advice for a particular patient may not always be obvious. A useful strategy may be to ask the patient: − “What do you not like about being a smoker?” The patient’s answer to this question can be built upon by you with more detailed information on the issue raised. − Example: Doctor: “What do you not like about being a smoker?” Patient: “Well, I don’t like how much I spend on tobacco.” Doctor: “Yes, it does build up. Let’s work out how much you spend each month. Then we can think about what you could buy instead!”

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IV. TH E 5A’S MODEL TO HELP PATIENTS READY TO QUIT TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

5A’s Assess Determine readiness to make a quit attempt

Action

Strategies for implementation

• Ask two questions in relation to • Any answer in the shaded area indicates that the tobacco user is NOT “importance” and “self-efficacy”: ready to quit. In these cases you should deliver the 5 R’s intervention 1. “Would you like to be a non(see Session V). tobacco user?” Question 1 Yes Unsure No 2. “Do you think you have a Question 2 Yes Unsure No chance of quitting successfully?” • If the patient is ready to go ahead with a quit attempt you can move on to Assist and Arrange steps.

Assist Help the patient with a quit plan

• Use the STAR method to facilitate and help your patient to develop a quit plan: − Set a quit date ideally within two weeks. • Provide practical counseling − Tell family, friends, and coworkers about quitting, and ask for support. • Provide intra-treatment social − Anticipate challenges to the upcoming quit attempt. support − Remove tobacco products from the patient’s environment and make the home smoke free. • Provide supplementary materials, including information on quit • Practical counseling should focus on three elements: lines and other referral resources − Help the patient identify the danger situations (events, internal states, • Help the patient develop a quit plan • Recommend the use of approved medication if needed or activities that increase the risk of smoking or relapse). − Help the patient identify and practice cognitive and behavioral coping skills to address the danger situations. − Provide basic information about smoking and quitting • Intra-treatment social support includes: − Encourage the patient in the quit attempt − Communicate caring and concern − Encourage the patient to talk about the quitting process • Make sure you have a list of existing local tobacco cessation services (quit lines, tobacco cessation clinics and others) on hand for providing information whenever the patient inquires about them. • The support given to the patient needs to be described positively but realistically.

Arrange • Arrange a follow-up contact with • When: The first follow up contact should be arranged during the first Schedule follow-up your TB patient either in person week. A second follow up contact is recommended within one month contacts or a referral or by telephone. after the quit date. to specialist support • Refer the patient to specialist • How: TB patients being treated under DOTS will regularly visit TB care support if needed facilities at least three times a week. Please set a day after one week to talk again about their quit attempts. Following up with patients is recommended to be done though teamwork if possible. • What: For all patients: − Identify problems already encountered and anticipate challenges. − Remind patients of available extra-treatment social support. − Assess medication use and problems. − Schedule next follow up contact. For patients who are abstinent: − Congratulate them on their success. For patients who have used tobacco again: − Remind them to view relapse as a learning experience. − Review circumstances and elicit recommitment. − Link to more intensive treatment if available.

IV. T H E 5 A’S MO D E L T O H E L P PAT IE N T S R E AD Y T O Q U IT TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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V. The 5 R’s model

to increase motivation to quit

The 5 R’s - relevance, risks, rewards, roadblocks, and repetition – are the content areas that should be addressed in a motivational counseling intervention to help those who are not ready to quit. If your TB patient doesn’t want to be a non-tobacco user (doesn’t think that quitting is important), please focus more time on “Risks” and “Rewards”. If your patient wants to be a non-tobacco user but doesn’t think he or she can quit successfully (doesn’t feel confident in their ability to quit), please focus more time on the “Roadblocks”. If patients remain not ready to quit, end positively with an invitation to them to come back to you if they change their minds. Table 4 summarizes some useful strategies for delivering a brief motivational intervention in primary are. Table 4. The 5R’s brief motivational intervention for TB patients not ready to quit 5R’s Relevance Strategies for implementation Encourage the patient to indicate how quitting is personally relevant to him or her as a TB patient. Motivational information has the greatest impact if it is relevant to a patient’s disease status(in this case, TB) or risk, family or social situation (e.g. having children in the home), health concerns, age, sex, and other important patient characteristics (e.g. prior quitting experience, personal barriers to cessation). Risks Encourage the patient to identify potential negative consequences of tobacco use that are relevant to a TB patient. Examples of risks are: • Short-term risks: TB treatment outcomes. TCP: “What do you know about the risks of smoking to your health? What particularly worries you?”¨ P: “I know it could make the TB treatment less successful. That must be awful.” Example TCP: “How is quitting most personally relevant to you?” P: “I suppose smoking is bad for my health.”

• Long-term risks: increased risk of TB relapse, TB related deaths, TCP: “That’s right – the risk of recurrent TB is 2-3 heart attacks and strokes, lung and other cancers (e.g. larynx, times higher among smokers.” oral cavity, pharynx, esophagus), chronic obstructive pulmonary diseases, osteoporosis and long-term disability. • Environmental risks: increased risk of TB infection and TB disease in spouse and children. Rewards Ask the patient to identify potential relevant benefits of stopping tobacco use. Examples of rewards could include: − improved TB treatment outcomes; − food will taste better; − improved sense of smell; − saving money; − feeling better about oneself at the same time that TB is being cured; − home, car, clothing and breath will smell better; − setting a good example for children and decreasing the likelihood that they will smoke; − having healthier babies and children; − feeling better physically; − performing better in physical activities. TCP: “Do you know how stopping smoking would affect your TB treatment outcomes?” P: “I guess it would be more successful if I quit.” TCP: “Yes, and it will significantly improve your TB treatment outcomes. And it’s important to quit as soon as possible.”

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V. TH E 5 R ’S MODEL TO INCREASE MOTIVATION TO QUIT TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

5R’s Roadblocks

Strategies for implementation Ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counselling, medication) that could address barriers. Typical barriers might include: − withdrawal symptoms; − fear of failure; − weight gain; − lack of support; − depression; − enjoyment of tobacco; − being around other tobacco users; − limited knowledge of effective treatment options. Repeat assessment of readiness to quit. If still not ready to quit repeat intervention at a later date. The motivational intervention should be repeated every time an unmotivated TB patient visits the clinic setting.

Example TCP: “So what would be difficult about quitting for you?” P: “Cravings – they would be awful!” TCP: “We can help with that. We can give you nicotine replacement therapy (NRT) that can reduce the cravings.” P: “Does that really work? TCP: “You still need will-power, but study shows that NRT can double your chances of quitting successfully.”

Repetition

TCP: “So, now we’ve had a chat, let’s see if you feel differently. Can you answer these questions again…?””¨ (Go back to the Assess stage of the 5A’s. If ready to quit then proceed with the 5A’s. If not ready to quit, end intervention positively by saying “This is a difficult process but I know you can get through it and I am here to help you”.)

TCP: TB care provider; P: patient

V. T H E 5 R ’S MO D E L T O IN CR E ASE MO T IVAT IO N T O Q U IT TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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VI. The 5A’s to avoid exposure to secondhand smoke If your patient is a non-smoker you can offer a brief advice to inform them about the dangers of secondhand smoke (SHS) and help them avoid exposure to SHS. Please find below actions and strategies for using the 5A’s model to help patient avoid exposure to SHS (Table 5). Table 5. The 5A’s brief tobacco interventions for reducing TB patients’ exposure to SHS 5A’s Ask Systematically identify non-smoking TB patients who are exposed to SHS at every visit Action • Ask ALL of your non-smoking patients at every encounter if they are exposed to SHS. • Record the response on the TB treatment card. • Make it part of your routine. Advise • Educate the TB patient about the • Your advice should be clear, positive, and tailored to that specific dangers of SHS and advise them patient’s characteristics and circumstances. For example, “There is no Persuade the patient to avoid it. safe level of exposure, it is important that you avoid exposure to SHS, to avoid exposure to SHS which may dramatically reduce e your respiratory symptoms.” Assess Determine the patient’s willingness to reduce exposure to SHS • Assess if the patient is willing to reduce his or her SHS or not. • Assess where the patient is exposed to SHS and whether there is a possibility to reduce the patient’s exposure. • Have your patient list off all the common places where they can be around secondhand smoke. Common examples include: − Place of employment − Restaurants − Bars − Their home − Recreational settings • Encourage your patient to assess the possibility of reduce exposure to SHS in each place. Some places, for example, exposure to SHS at home, the patient would have a high possibility to reduce exposure by encouraging his or her family to quit or to smoke outside. Assist • Assist your patient in developing Help the patient in an action plan to reduce their making an attempt exposure to SHS. to make his or her daily life environment smoke-free • Use MAD-TEA to help your patient plan what they can do: − Meet their friends at spaces in the community that are smoke free − Ask family members and visitors to smoke outside − Declare their home and personal spaces (e.g. their car) to be smoke free − Talk to family members and people they work with about the risks of secondhand smoke − Encourage family members, friends, and workmates who smoke to stop − Advocate comprehensive smoke-free laws or regulations in workplaces and public places. Strategies for implementation • Keep it simple. For example: – “Does anyone else smoke around you” • Countries should consider including the information on SHS in TB treatment card.

Arrange Schedule follow-up contacts

• Arrange a follow-up contact • When: The first follow up contact should be arranged after one week. after around one week to provide • How: TB patients being treated under DOTS will regularly visit TB care necessary support. facilities at least three times a week. Please set a day after one week to talk again about their attempts to avoid SHS. Following up with patients is recommended to be done through teamwork if possible. • What: − Congratulate them on their success if the patients have reduced exposure. − Identify problems already encountered and anticipate challenges. − Provide necessary support. − Schedule next follow up contact.

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V I. TH E 5A’S TO AVOID EXPOSURE TO SECONDHAND SMOK E TO O LK IT FO R DELIVERING THE 5A’S AND 5R’S BRIEF TOBA CCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

REFERENCES AND RESOURCES 1. World Health Organization. A WHO/The Union monograph on TB and tobacco control: joining efforts to control two related global epidemics. Geneva: World Health Organization, 2007. (http://www.who.int/tobacco/resources/publications/tb_tob_control_monograph/en/, accessed 15 June 2013). 2. Sitas F, Urban M, Bradshaw D, Kielkowski D, Bah S, Peto R. Tobacco attributable deaths in South Africa. Tob Control 2004;13:396-9. 3. Lönnroth K, Raviglione M. Global epidemiology of tuberculosis: Prospects for control. Semin Respir Crit Care Med 2008; 29: 481-491. 4. Awaisu A, Nik Mohamed MH, Mohamad Noordin N, Muttalif RA, Abd Aziz N, Syed Sulaiman SA, et al. Impact of connecting tuberculosis directly observed therapy short-course with smoking cessation on health-related quality of life. Tob Induc Dis. 2012; 10(1): 2. 5. WHO Capacity Building for Tobacco Control Training Package 4: Strengthening health systems for treating tobacco dependence in primary care. Geneva, World Health Organization, 2013. (http://www.who.int/tobacco/publications/building_capacity/training_package/treatingtobaccodependence/en/index. html, accessed 15 June 2013). 6. Global tuberculosis control: epidemiology, strategy, financing: WHO report 2009. Geneva, World Health Organization, 2009. 7. Global tuberculosis control: WHO report 2010. Geneva, World Health Organization, 2010. 8. Global tuberculosis report 2012. Geneva, World Health Organization, 2012. 9. Kaur J, Sachdeva KS, Modi B, Jain DC, Chauhan LS, Dave P, et al. Promoting tobacco cessation by integrating 'brief advice' in tuberculosis control programme. WHO South-East Asia J Public Health 2013;2:28-33. 10. Leung C, Li T. Lam T. Yew W, Law W, Tam C, et al. Smoking and tuberculosis among the elderly in Hong Kong. Am J Respir Crit Care Med 2004, 170:1027-33. 11. Awaisu A, Nik Mohamed MH, Mohamad Noordin N, Abd Aziz N, Syed Sulaiman SA, Muttalif RA, et al. The SCIDOTS Project: Evidence of benefits of an integrated tobacco cessation intervention in tuberculosis care on treatment outcomes. Subst Abuse Treat, Prev, Pol. 2011;6:26. 12. WHO report on the global tobacco epidemic, 2009: implementing smoke-free environments. Geneva, World Health Organization, 2009. (http://www.who.int/tobacco/mpower/2009/en/, accessed 15 November 2012). 13. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco. Geneva, World Health Organization, 2011. (http://www.who.int/tobacco/global_report/2011/en/, accessed 15 November 2012). 14. East Tennessee State University. If you are not yet ready to quit. (http://www.etsu.edu/tips/education/notready.aspx, accessed 15 November 2012). 15. Cancer Council New South Wales. The impacts of smoking and the benefits of quitting (http://askthequestion.com.au/wp-content/uploads/2011/11/CAN3249-The-impacts-of-smoking-with-references.pdf, accessed 15 June 2013). 16. Nishori R, Weaver R. What are the physical, social and financial affects of smoking. (http://www.lshtm.ac.uk/aboutus/introducing/volunteering/pastprojects/10projects/1102reeceandrisanpresentation.pdf, accessed 15 June 2013).

ACKNOWLEDGEMENTS The World Health Organization gratefully acknowledges Elisabeth Gundersen and Thomas Milko for drafting this toolkit.

R E F E R E N CE S AN D R E SO U R CE S – ACKN O W L E D G E ME N T S TOOLKIT F OR DELIVERING THE 5 A’ S AN D 5 R ’ S BR IE F T O BACCO IN T E R VE N T IO N S T O T B PAT IE N T S IN PR IMARY CAR E

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