● Expressing empathy : Is important in addressing smoking or other tobacco use. The clinician shows acceptance and respect for the patient’s autonomy and ability to implement change. The goal is to help patients weigh the pros and cons in order that they will make the decision for themselves: ○ Asking open-ended questions that cannot be answered by yes, no, or another single-word response is essential to establishing patient rapport: “How important do you think it is for you to quit smoking? What are your concerns about quitting? What are the benefits of quitting? What might happen if you quit?” ○ Reflective listening can be used to foster a shared understanding. The clinician should reflect the patient’s words or meaning – “So you think smoking helps you to maintain your weight” – and summarize what the patient has expressed: “What I have heard so far is that smoking is something you enjoy. On the other hand, your boyfriend hates your smoking, and you are worried you might develop a serious disease.” ○ The patient’s feelings and concerns should be normalized: “Many people worry about managing without cigarettes.” ○ The patient’s autonomy and right to choose or reject change must be supported and respected: “I hear you saying you are not ready to quit smoking right now. I respect your decision and I’m here to help you when you are ready.” ● Developing discrepancy : Highlights the inconsistency between the patient’s present behavior and his or her expressed priorities, values, and goals (e.g., “It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?”). Tipping the scales between the pros and cons of continued The Five R’s The “Five R’s” is a method developed by the authors of the Treating Tobacco Use and Dependence: 2008 Update clinical guideline to assist the clinician in discussing the topic areas that can be useful in encouraging patients who are not ready to make a quit attempt. The Five R’s are relevance, risks, rewards, roadblocks, and repetition. The Five R’s are most effective when used in the motivational interviewing style: 1. Relevance : The clinician should encourage the patient to indicate, as specifically as possible, why quitting is personally relevant. A patient is most likely to quit smoking due to reasons relevant to his or her disease status, risk factors, family circumstances, or social situation (e.g., health concerns, age, gender, prior quitting experience, having children in the home, personal barriers to cessation). 2. Risks : The clinician should ask the patient to identify potential negative consequences of tobacco use. With the patient’s permission, the clinician may suggest or highlight those risks that seem most relevant to the patient; however, the interview should attempt to elicit the risks that the patient perceives as most immediate and important. If the patient offers compromised solutions such as smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes), the clinician should inform the patient that these will not eliminate the risks. Examples of acute risks are shortness of breath, exacerbation of asthma, increased risk of respiratory infections, harm to pregnancy, impotence, and infertility.
smoking helps the patient to develop the motivation to change. ○ The clinician should reinforce and support “change talk” and “commitment” language: “So, you realize how smoking is affecting your breathing and making it hard to keep up with your kids.” “It’s great that you are going to quit when you get through this busy time at work.” ○ Build and deepen commitment to change: “There are effective treatments that will ease the pain of quitting, including counseling and many medication options.” “We would like to help you avoid a stroke like the one your father had.” ● Rolling with resistance : Is an important tool that enables the clinician to avoid confrontation and handle patient resistance. When faced with change, it is human nature to resist it. Resistance may manifest not only in patients’ words but in their body language as well (e.g., leaning away from the clinician, crossing their arms). The clinician should back off and use reflection when the patient expresses resistance: “Sounds like you are feeling pressured about your smoking.” “You are worried about how you would manage withdrawal symptoms.” The clinician should ask permission before providing information: “Would you like to hear about some strategies that can help you address that concern when you quit?” ● Supporting self-efficacy : Helps the patient to identify and build on past successes: “So you were fairly successful the last time you tried to quit.” The clinician should offer options for achievable small steps toward change and reinforce them with praise. Patients may wish to read about quitting benefits and strategies (see the Resources section). A change in smoking patterns (e.g., no smoking in the home) should be encouraged, and patients should be asked to share their ideas about potential quitting strategies. Long-term risks include oral disease, heart attack, stroke, lung and other cancers, chronic bronchitis, emphysema, osteoporosis, long-term disability, and need for extended care. Examples of environmental consequences are increased risk of lung cancer and heart disease in cohabitants; increased risk for pregnant women of low birth-weight infants; and sudden infant death syndrome (SIDS), asthma, middle-ear disease, and respiratory infections in children in smoking households. 3. Rewards : The clinician should ask the patient to identify potential benefits of stopping tobacco use. Information about the rewards of quitting provided by the patient has the most motivational value. Examples of rewards are as follows: ○ Improved health. ○ Better-tasting food. ○ Improved sense of smell. ○ Saving money. ○ Feeling better about oneself. ○ Better-smelling home, car, clothing, and breath. ○ 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. ○ Improved appearance, including reduced wrinkling/ aging of skin and whiter teeth. 4. Roadblocks : The clinician should ask the patient to identify barriers or impediments to quitting. When the pros (rewards) for quitting outweigh the cons (roadblocks), the patient’s motivation to make a quit
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