Smoking CessationUsing motivational interviewing

Welcome!

• Introductions

• CS2day Collaboration

• Brief Activity Overview

• Your Faculty

• A Comment about Video

And a word about this program…

The CAFP committee on Continuing Professional Development is responsible for management and resolution of conflict for any individual who may have influence on content, who have served as faculty, or who many produce CME/CPD content for the CAFP. Dr. Lee and Dr. Mitchell state that neither have any financial conflicts to disclose. This activity is funded by an unrestricted educational grant from Pfizer.

Meet yourInstructors

Event 1 of 3

Jay Lee Suzanne Mitchell

The Five A’s

1.Ask

2.Advise

3.Assess

4.Assist

5.Arrange

ASK… about smoking status at every adult patient visit

Barrier Busters• 70 percent of smokers want to

quit

• More likely to quit if advised

• Many doctors never ask

• Only takes 3 minutes

• Payment plan

Advise… your patients to quit smoking

Assess… your patient’s current willingness to quit smoking

Tools for Assessing

After providing a clear, strong, and personalized message to quit, you must determine whether the patient is willing to quit at this time.

“Are you willing to try to quit at this time? I can help

you.”

And There is the Problem: How do you Assess and Proceed?And avoid thelecture.

The Problem

• Current models of care are paternalistic

• Communication is provider-centered, not patient-centered

• Information giving vs information exchange

• A focus on save the patient vs patients save themselves

• Labeling of patient: “in denial” or “difficult”

• Compliance vs adherence

• Dictate rather than negotiate behavior change

The Problem (cont.)• Resistance is seen as a flaw rather than useful

information to explore

• Little time spent identifying how patients make sense of illness and treatment – or what benefits they derive from tobacco

• What do they know and understand about the risk of not treating the illness?

• Schools teach docs that you are the expert

• New models of communicating with patients are needed

Motivational InterviewingMiller and Rollnick

Motivational interviewing is a person-centered directive

(guided) method of communication for enhancing

intrinsic motivation to change by exploring and resolving

ambivalence and resistance.

The Spirit of Motivational Interviewing• Empathy

• Caring

• Collaboration

• Patient is the focus

Let’s explore the key concepts…

The Goals for MI

• Establish empathic partnership

• Elicit change talk

• Promote positive behavior change

The Challenges in Health Behavior Change

• Resistance

• Ambivalence

• Discrepancy

#1: Resistance• When people resist change, the

worst strategy is persuasion

• When they are resistant, the cons >pros

• When faced with resistance, explore don’t explain

• Two types of resistance

Issue Resistance“I am not ready to quit smoking. It relaxes

me.”

“I am so tired of you people hounding me about my smoking. Everyone acts like it’s so easy.”

Relational Resistance

Inappropriate Responses to Resistance

• Persuasion

• The Righting Reflex

• Give more information

#2: Ambivalence

• When people are ambivalent, the pros = cons

#3: Lack of Discrepancy

• Unaware when behaviors contradict values

The MI Skills We Use

• Roll with resistance

• Express empathy

• Avoid argumentation

• Amplify Ambivalence

• Develop discrepancy

• Support self-efficacy

The MI Tools We Use

• Explore line of reasoning

• Provide a menu of options

• Confidence rulers

• A look over the fence

Rulers• Two types: Importance and

Confidence• Scale from 1 to 10• “How important is this change for

you?”• “How confident are you that you

can make this change if you want to?”

• “Why did you choose a ____, not a 1?”

• Using this elicits change talk

The Results We Get

• Importance, confidence, & readiness

• Autonomy

• Respect/Understanding

Case Study: Asthma

• Julie Stockton is a 37-year-old Caucasian female

• Daughter, Sara, age10, has asthma

• Julie, the mother, is a smoker

• When asked about this, Julie says defensively, “Don’t bother to talk to me about my smoking. I smoke outside so it doesn’t affect Sara’s asthma.”

30

Roll With Resistance

Remember:

Relational Resistance-Roll with resistance-Express empathy-Avoid argumentation

Issue Resistance-Express empathy-Develop discrepancy-Support self-efficacy

Roll With Resistance Example

Patient: I just don’t see how I can quit smoking when my wife smokes too and she won’t quit.

Doctor: You suspect that it will be much more difficult for you to quit smoking if your wife continues to smoke.

Patient: Right…I just don’t see that working.

Doctor: How important is it for you to quit right now?

Roll With ResistanceYou try it.

Roll with Resistance: You Try It

Patient: “Other people have blood pressure that is much higher than mine. Mine is not so bad. I’m not worried.”

Express Empathy

Ways to Express Empathy• Active listening and reflection

• Repeat back the words with feeling

• Slight or major paraphrase

• Example starters…

“You seem_____”

“In other words…”

“You feel ___ because ___”

“It seems to you…”

“You seem to be saying…”

“You sound…”

Express Empathy Example

Patient: “Everyone makes it sound so easy…just take the medicine, quit smoking, change your diet, and exercise more!”

Doctor: “You sound frustrated. You have been asked to make a lot of changes to control your diabetes and blood pressure and people don’t seem to appreciate how overwhelming and difficult all of it can be.”

Express EmpathyYou try it.

Express Empathy: You Try It

Patient: “I know smoking is bad for me, it’s just that all of my friends smoke and we hang out together.”

Avoid Argumentation

Avoid Argumentation ExamplePatient: “My doctor says I need to lose weight,

take the medicine, quit smoking, and reduce the salt in my diet. I don’t think I need to quit smoking, do you? How about cutting back?”

Doctor: “It sounds like a lot to do. It’s great that you are willing to take your medicine and watch your salt intake. Cutting back on your smoking would be a great first step. Ultimately, quitting smoking would be the healthiest thing to do. What are your thoughts?”

Avoid Argumentation: You Try It

Patient: “I feel fine. I don’t need to quit smoking.”

Develop Discrepancy

Develop Discrepancy Example(On the one hand….and then, on the other…)

Patient: “I want to lower my blood pressure and reduce my risk of stroke or heart attack but I don’t want to quit smoking.”

Doctor: “On the one hand, you really don’t feel like you want to stop smoking now, but you can also see that smoking raises your blood pressure and interferes with your goal to avoid a stroke or heart attack.”

Then You Urge Them to “Look Over the Fence”…

• “If you were to wake up tomorrow and you were no longer a smoker, what would you like about that? What would be the benefits to you?”

• “If you made no change and kept smoking, what would that look like to you a year from now? How would you feel?”

Develop Discrepancy: You Try it

• Patient: “I’ve tried to quit smoking but I just can’t seem to do it. I’d like to quit but I need the smoking to lower my stress.”

Support Self-Efficacy

Support Self-Efficacy Example

Patient: “I don’t think I am ready to walk four days a week, but I am willing to try twice a week.”

Doctor: That sounds like a great start and will really help with your osteoporosis.

Supporting Self-Efficacy: You Try It

• Patient: “I’ve thought a little more about what you said about quitting smoking. I think I’m ready to try cutting back.”

It’s a Wrap!

A Few Housekeeping Details• Any one needing an extra SL

tutorial?

• Next week, same time, same place (make a landmark)

• Be sure to have a headset for next week

Welcome Back

Event 2 of 3

Plan for Event #2

• Any questions from last week’s event?

• Model Interview

• Teleport to red and blue platforms for role playing

• Return to this place, at the end, for a wrap up

Homework

Welcome Back

Event 3 of 3

Tonight’s Plan

• Discuss the video homework

• Short presentation

• Up to platforms for more role-play practice

• Return to this place, at the end, for a wrap up

Assist… your patients in understanding the physical and behavioral implications of tobacco addiction

What do people get from smoking?• Physical benefits

• Addiction to baseline nicotine blood levels• Avoidance of withdrawal symptoms• Enjoyment of the “rush”• Weight loss

• Behavioral benefits• The rituals• Pleasurable associations• The “secondary gain” (cigarette breaks)• Social camaraderie• Self reward• Image enhancement

Treatment Options

• Non-Pharmacologic:• Cold Turkey• Gradual Tapering• Behavioral Modification• Aversion Therapy• Reward Systems• Physician Counseling• Scare Tactics• Guilt• Group Support

Quit Plan• Action – Help the patient with a quit plan

• Set a quit date (should be within 2 weeks)

• Tell family, friends, and coworkers you are quitting; request understanding & support

• Anticipate challenges to the upcoming quit attempt

• Remove tobacco products from your environment

• Prior to quitting, avoid smoking in places where you spend a lot of time (e.g. work, home, car)

Tools for AssistingDesign a plan – cold turkey

• Set a date• Throw away cigarettes & tools

(lighter, cigarette case)• Throw away ashtrays• Dental appointment for

teeth cleaning• Dry clean your clothes• Chewing gum• Exercise

Tools for AssistingDesign a Plan – Gradual Tapering

• Set a date• Plan the taper• When down to a few cigarettes,

follow “Cold Turkey” plan

Tools for AssistingDesign a Plan – Behavioral Modification

• Cigarette diary• Break patterns• Smoking as a solitary activity• Don’t smoke in the car or house• Don’t smoke until 30 min after meal

Treatment OptionsPharmacologic:

• Bupropion SR• Nicotine gum• Nicotine inhaler• Nicotine lozenge• Nicotine nasal spray• Nicotine patch• Varenicline

Treatment Option Questions

• What other factors may influence medication selection?

• What medications should be used with a highly nicotine dependent patient?

• Is medication adherence important?

• May medications ever be combined?

Treatment Option Questions• Should we avoid nicotine

replacement therapies in patients with a history of C-V disease?

• Are there special medications for patients with history of depression?

• Which medications for patients particularly concerned about weight gain?

Comparison of Therapeutic Efficacy

• Meta-analysis (70 published report of 69 trials) of placebo-controlled RCTs

• Total of 32,908 subjects

• Seven pharmacotherapies studied• Bupropion • Nicotine tablet• Nicotine gum • Transdermal

• Varenicline• Nicotine inhaler • Nicotine nasal spray

Eisenberg M, et al. CMAJ. 2008;179:35-144

Results

Eisenberg M, et al. CMAJ. 2008;179:35-144

• Of the 7 pharmacotherapies studied, all but nicotine inhaler were found to be more efficacious than placebo• Varenicline• Nicotine nasal spray• Bupropion• Transdermal nicotine• Nicotine tablet• Nicotine gum

Instant Gratification• After quitting for 20 minutes:

• Blood pressure decreases• Pulse rate drops• Improved peripheral circulation

• After 8 hours:• Carbon monoxide level drops to normal

• After 24 hours:• Heart attack risk decreases

• After 48 hours• Enhanced taste and smell

Intermediate Gratification• After quitting for two weeks to three

months:• Circulation improves• Walking becomes easier• Lung function improves

• After one to nine months:• Cough, sinus congestion, fatigue and

shortness of breath improve

• After one year:• Heart disease risk reduced by half

Long Term Gratification• After 5 to 15 years:

• Stroke risk is reduced to baseline• Lung cancer risk is halved• Risk of oral, esophageal, bladder, renal

and pancreatic cancer decreases

• After 15 years• CAD risk similar to those who never

smoked• Risk of death near baseline

Arrange… to follow up with your patients to monitor their smoking cessation progress

Tools for Arranging• Schedule follow-up within one

week after the quit date• Telephone contact• Email/text message reminders• Quit lines

• The majority of relapse occurs in the first two weeks

Thank you.