Using Motivational Interviewing to Help Your Patients Quit Smoking

Scott M. Strayer, MD, MPH Associate Professor of Family Medicine University of Virginia Health System

Disclosures Scott M. Strayer, MD, MPH disclosed that he has no financial relationships related to this presentation. CS2day is supported by an educational grant from Pfizer Inc.

Sound Familiar?

“I tell them what to do, but they won’t do it.” “It’s my job just to give them the facts, and that’s all I can do.” “These people lead very difficult lives, and I understand why they smoke.” “Some of my patients are in complete denial.”

Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.

Why Do Our Patients Struggle?

(“strong” endorsements by physicians) poor self-discipline poor will-power not scared enough not intelligent enough 53.2% 50.0% 36.9% 16.3% Polonsky, Boswell and Edelman, 1996

Algorithm for Treating Tobacco Use

YES YES

Is patient now willing to quit?

Does patient now use tobacco?

See Chapter 2

NO NO YES

Did patient once use tobacco?

NO

Provide appropriate tobacco dependence treatments

See Chapters 3A and 4

Promote motivation to quit

See Chapter 3B

Prevent relapse*

See Chapter 3C

a *Relapse prevention interventions are not necessary in the case of the adult who has not used tobacco for many years.

Encourage continued abstinence

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For the Patient Unwilling to Quit

What Should we do?

Explain what patients could do differently in the interest of their health?

Advise and persuade them to change their behavior?

Warn them what will happen if they don’t change their ways?

Take time to counsel them about how to change their behavior?

Refer them to a specialist?

Rollnick, Miller and Butler. Motivational Interviewing in Healthcare. 2008.

Treatment Recommendations: Counseling

For Smokers Not Willing to Make a Quit Attempt at This Time

Recommendation: Motivational intervention techniques appear to be effective in increasing a patient’s likelihood of making a future quit attempt; therefore, clinicians should use motivational techniques to encourage smokers who are not currently willing to quit to consider making a quit attempt in the future (strength of evidence = B)

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Definition of MI

“…a client-centered, directive counseling method for enhancing intrinsic motivation to change by exploring and resolving ambivalence .” Miller, W.R. & Rollnick, S.(2002)

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“People are generally better persuaded by the reasons they have themselves discovered, than by those which have come into the mind of others.”

Pascal, 17th Century

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Motivation for Change

Motivation is an intrinsic process Ambivalence Alternative behaviors have pluses and minuses Motivation arises out of discrepancy Values/goals conflict with current behavior Ambivalence  discrepancy  change “Change Talk” facilitates change

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Integrating the Behavioral Theories

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Decisional Balance An explanatory model of behavior change

Highlights the individual’s behavior

ambivalence

regarding maintaining vs changing a it is a balancing of the costs of status quo with the costs of change and the benefits of change with the benefits of the status quo.

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Decisional Balance

Costs of Status Quo Benefits of Change Miller, W.R. & Rollnick, S.(2002) Costs of Change Benefits of Status Quo

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The Righting Reflex

The Best Intentions Can Backfire Most patients are ambivalent about unhealthy behaviors.

When we (physicians) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change.

The patient’s natural response is to defend the

opposite

(no change) side of the ambivalence coin.

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The Spirit of Motivational Interviewing

Collaboration Confrontation Evocation Education vs.

Autonomy Authority “Dance” Miller, W.R. & Rollnick, S.(2002) “Wrestling”

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Motivational Interviewing

Five Key Elements (DARES)

1.

D

evelop discrepancy 2.

A

void argumentation/

R

oll with resistance 3.

E

xpress empathy 4.

S

upport self-efficacy

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Step 1: Express Empathy

Acceptance facilitates change.

Skillful reflective listening is fundamental.

Ambivalence is normal.

Miller, W.R. & Rollnick, S.(2002)

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Step 2: Develop Discrepancy

The patient should present the arguments for change.

Change is motivated by a perceived discrepancy between present behavior and important personal goals or values.

Miller, W.R. & Rollnick, S.(2002)

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Step 3: Avoid Argumentation/ Roll with Resistance

Avoid arguing for change Resistance is not directly opposed.

New perspectives are offered if invited, but not imposed The patient, not the doctor, is the primary resource in finding answers & solutions.

Resistance is a signal to respond differently

Reframing Emphasizing personal choice & control

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Step 4: Support Self-Efficacy

Belief in the possibility of change is an important motivator.

The patient, not the MD, is responsible for choosing and carrying out change.

The MD’s own belief in the person’s ability to change becomes a self fulfilling prophecy.

Miller, W.R. & Rollnick, S.(2002)

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“Early” Methods to Enhance Motivation (OARS)

1.

2.

3.

4.

Open-ended questions

- get the patients agenda

Affirm

- reinforce statements or actions that promote change

Reflective listening

trying to say.

—ie, listen &

reflect back what you think they’re

Summarize

- distill the key elements of what the patient has told you in terms of decisional balance & any change talk

.

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More “Early” Methods to Enhance Motivation Elicit change talk

- 4 types Intention to change.

Disadvantages/advantages of the status quo Advantages/disadvantages of change.

Optimism about capacity to change.

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The “Readiness Ruler”- Importance/Confidence Scales

“On a scale from 0 to 10, how

important

would you say it is for you to ____, where 0 is not at all important, and 10 is extremely important.” “Again, on the 10-point scale, how

confident

are you that if you decided to ____, you could do it?” Responses to patient’s responses: Why are you a _ and not a zero?” What would it take to get you from a _ to a higher number?”

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Trigger Questions

to Elicit Change Talk

Advantages of the status quo: “What do you like about ______?

Disadvantages of the status quo: “What problems have you experienced in relation to your ___?” Advantages of change: “What would be the good things about ___?” Disadvantages of change: “What would be the bad things about _______?

Optimism about change: “How confident are you that you can ___?” or “What do you think would work for you, if you decided to ___?”

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More Trigger Questions

Intention to change: “What would you be willing to do?” or stronger language: “What do you intend to do?” Explore extremes: “What’s the worst thing about your ___? What would be the best thing about changing?”

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Strategies to Enhance Confidence

Review past successes Elicit personal strengths and supports Brainstorming Hypothetical change (“If you were able to quit smoking tomorrow, how do you think things would be different?”)

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Traps to Avoid

Expert trap:

problem-solving, prescribing the solution makes patient the passive recipient and undermines building intrinsic motivation

Labeling:

evokes dissonance & focuses energy unnecessarily on the label (esp. with addiction problems).

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Other Traps to Avoid

Premature focus:

patient needs to be ready (determine stage of change)

Blaming:

MD must attempt to render blame irrelevant (including

self

-blame): shame & blame usually squash self efficacy & intrinsic motivation to change.

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Strengthening Commitment

Summarize patient’s own perception of problem, ambivalence, desire/intention to change, and can include your own assessment.

Ask a “key question”, ie: “What is the next step?”

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Negotiating a Change Plan

Setting goals Have patient develop a

menu

strategies —brainstorm.

of Have patient decide on a specific plan & summarize it.

Elicit commitment Have patient restate what they intend to do.

Involve others: the more the patient verbalizes the plan to others, the more commitment is strengthened (“no going back now” concept)

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For the Patient Unwilling to Quit: The “5 R’s”

R

elevance

R

isks Encourage the patient to indicate why quitting is personally relevant, being as specific as possible Motivational information has the greatest impact if it is relevant to a patient’s disease status or risk, family, or social situation (eg, having children in the home), health concerns, age, gender, and other important patient characteristics (eg, prior quitting experience, personal barriers to cessation) The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (eg, smokeless tobacco, cigars, and pipes) will not eliminate these risks. Examples of risks are 

Acute risks:

Shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, infertility 

Long-term risks:

Heart attacks and strokes, lung and other cancers (eg, larynx, oral cavity, pharynx, esophagus, pancreas, stomach, kidney, bladder, cervix, and acute myelocytic leukemia), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), osteoporosis, long-term disability, and need for extended care 

Environmental risks:

spouses; increased risk for low birth weight, sudden infant death syndrome (SIDS), asthma, middle ear disease, and respiratory infections in children of smokers Increased risk of lung cancer and heart disease in

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For the Patient Unwilling to Quit: The “5 R’s”

(cont.) R

ewards The clinician should ask the patient to identify potential benefits of stopping tobacco use The clinician may suggest and highlight those that seem most relevant to the patient           Examples of rewards follow  Improved health Food will taste better Improved sense of smell Saving money Feeling better about yourself Home, car, clothing, breath will smell better Having healthier babies and children Setting a good example for children and decrease the likelihood that they will smoke Feeling better physically Performing better in physical activities Improved appearance, including reduced wrinkling/aging of skin and whiter teeth

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For the Patient Unwilling to Quit: The “5 R’s”

(cont.) R

oadblocks

R

epetition The clinician should ask the patient to identify barriers or impediments to quitting and provide treatment (problem-solving counseling, 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 The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful

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Obtaining the 2008 Guideline

The full text of the 2008 Guideline, www.ahrq.gov/path/tobacco.htm#clinic To order the 2008 Guideline and the various supplemental materials go to www.ahrq.gov/clinic/tobacco/order.htm

UW-CTRI www.ctri.wisc.edu

CS2day http://cs2day.org/

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More Information on MI

Literature on MI and information on training (MINT) www.motivationalinterview.org

Miller and Rollnick. Motivational Interviewing: Preparing People for Change. Guilford Press. New York and London. 2002 Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London. 2008

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Time to Practice

Think of some healthy change you’d like to make …but you aren’t certain you really want to (or you would have already done it!) 39

Persuasion Techniques

• Agree that speaker should make the change • Explain why the change is important • Warn of consequences of not changing • Advise speaker how to change • Reassure speaker that change is possible • Disagree if speaker argues against change • Tell the speaker what to do • Give examples of others (other patients, peers,

celebrities) who have made similar healthy changes 40

What Did You Think?

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Time to Practice

Think of some healthy change you’d like to make, but you just haven’t done it yet.

Now, let’s practice using the techniques to elicit change talk.

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What Did You Think?

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Time to Practice- The “Action Plan” Intervention

1. Identify area for behavior change

-Importance and confidence should be elevated

2. Determine a specific action plan

-Meaningful, action-oriented, measurable, behavioral

3. Make certain that goals are practical/achievable

-Break down, specify, and limit steps as needed

4. Ask about obstacles, and problem solve 5. Feed back your understanding of the plan Offer support/sincere encouragement, BUT: OFFER AS LITTLE ADVICE AS POSSIBLE!

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What Did You Think?

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