Using Motivational Interviewing to Help Your Patients Quit Smoking

Scott M. Strayer, MD, MPHAssociate Professor of Family Medicine

University of Virginia Health System

Disclosures Disclosures

Scott M. Strayer, MD, MPH Scott M. Strayer, MD, MPH disclosed that he has no disclosed that he has no

financial relationships related financial relationships related to this presentation. to this presentation.

CS2day is supported by an CS2day is supported by an educational grant from Pfizer educational grant from Pfizer

Inc.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 Why Do Our Patients Struggle?Struggle?

(“strong” endorsements by physicians)

poor self-discipline53.2%

poor will-power50.0%

not scared enough36.9%

not intelligent enough16.3%

Polonsky, Boswell and Edelman, 1996

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Algorithm for Treating Tobacco Use

Provide appropriatetobacco dependence

treatments

See Chapters3A and 4

Promote motivationto quit

See Chapter 3B

Prevent relapse*

See Chapter 3C

Encouragecontinuedabstinence

Is patient nowwilling to quit?

Did patient onceuse tobacco?

Does patient nowuse tobacco?

See Chapter 2YES

YES

NO

YES NONO

a

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

For the PatientUnwilling 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.

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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 a client-centered, directive counseling method for enhancing counseling method for enhancing intrinsic motivation to change by intrinsic motivation to change by exploring and resolving exploring and resolving ambivalenceambivalence.”.”

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 BalanceAn explanatory model of behavior change

Highlights the individual’s ambivalence regarding maintaining vs changing a behavior

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

Costs of Change

Benefits of Status Quo

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

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The Righting ReflexThe 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

Evocation

Autonomy

“Dance”

Confrontation

Education

Authority

“Wrestling”

vs.

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

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Motivational InterviewingFive Key Elements (DARES)

1. Develop discrepancy

2. Avoid argumentation/Roll with resistance

3. Express empathy

4. Support 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. Open-ended questions- get the patients agenda

2. Affirm- reinforce statements or actions that promote change

3. Reflective listening—ie, listen & reflect back what you think they’re trying to say.

4. 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 of strategies

—brainstorm. 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”

Relevance 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)

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

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For the Patient Unwilling to Quit: The “5 R’s” (cont.)

Rewards 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 tothe 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.)

Roadblocks 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

Repetition 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

CS2dayCS2day 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!)

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Persuasion TechniquesPersuasion Techniques

• Agree that speaker should make Agree that speaker should make the changethe change

• Explain why the change is Explain why the change is importantimportant

• Warn of consequences of not Warn of consequences of not changingchanging

• Advise Advise speaker how to change how to change• Reassure speaker that change is Reassure speaker that change is

possiblepossible• Disagree if speaker argues against Disagree if speaker argues against

changechange• Tell the speaker what to doTell the speaker what to do• Give examples of others (other Give examples of others (other

patients, peers, celebrities) who patients, peers, celebrities) who have made similar healthy changes have made similar healthy changes

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What Did You Think?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?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 solve5. Feed back your understanding of the planOffer support/sincere encouragement, BUT:OFFER AS LITTLE ADVICE AS POSSIBLE!

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What Did You Think?What Did You Think?