The document provides information about using motivational interviewing to help patients quit smoking. It discusses the key concepts of MI including expressing empathy, developing discrepancy, avoiding argumentation, and supporting self-efficacy. Treatment options that are discussed include pharmacotherapy, behavioral modification, and arranging follow-up to monitor progress.

1. Smoking Cessation Using motivational interviewing

2. Welcome! Introductions CS2day Collaboration Brief Activity Overview Your Faculty A Comment about Video

3. 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.

4. Meet your Instructors Event 1 of 3

5. Jay Lee Suzanne Mitchell

6. The Five A’s Ask Advise Assess Assist Arrange

7. ASK… about smoking status at every adult patient visit

8. 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

9. Advise… your patients to quit smoking

10. Assess… your patient’s current willingness to quit smoking

11. 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.”

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

13. 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

14. 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

15. Motivational Interviewing Miller and Rollnick

16. Motivational interviewing is a person-centered directive (guided) method of communication for enhancing intrinsic motivation to change by exploring and resolving ambivalence and resistance.

17. The Spirit of Motivational Interviewing Empathy Caring Collaboration Patient is the focus

18. Let’s explore the key concepts…

19. The Goals for MI Establish empathic partnership Elicit change talk Promote positive behavior change

20. The Challenges in Health Behavior Change Resistance Ambivalence Discrepancy

21. #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

22. 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

23. Inappropriate Responses to Resistance Persuasion The Righting Reflex Give more information

24. #2: Ambivalence When people are ambivalent, the pros = cons

25. #3: Lack of Discrepancy Unaware when behaviors contradict values

26. The MI Skills We Use Roll with resistance Express empathy Avoid argumentation Amplify Ambivalence Develop discrepancy Support self-efficacy

27. The MI Tools We Use Explore line of reasoning Provide a menu of options Confidence rulers A look over the fence

28. 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

29. The Results We Get Importance, confidence, & readiness Autonomy Respect/Understanding

30. 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.”

31. R oll With R esistance

32. Remember: Relational Resistance Roll with resistance Express empathy Avoid argumentation Issue Resistance Express empathy Develop discrepancy Support self-efficacy

33. 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?

34. R oll With R esistance You try it.

35. 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.”

36. E xpress E mpathy

37. 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…”

38. 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.”

39. E xpress E mpathy You try it.

40. 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.”

41. A void A rgumentation

42. Avoid Argumentation Example Patient: “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?”

43. Avoid Argumentation: You Try It Patient: “I feel fine. I don’t need to quit smoking.”

44. D evelop D iscrepancy

45. 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.”

46. 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?”

47. 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.”

48. S upport S elf-Efficacy

49. 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.

50. 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.”

51. It’s a Wrap!

52. 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

53. Welcome Back Event 2 of 3

54. 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

55. Homework

56. Welcome Back Event 3 of 3

57. 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

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

59. 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

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

61. Quit Plan Action – Help the patient with a quit plan S et 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)

62. Tools for Assisting Design 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

63. Tools for Assisting Design a Plan – Gradual Tapering Set a date Plan the taper When down to a few cigarettes, follow “Cold Turkey” plan

64. Tools for Assisting Design 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

65. Treatment Options Pharmacologic: Bupropion SR Nicotine gum Nicotine inhaler Nicotine lozenge Nicotine nasal spray Nicotine patch Varenicline

66. 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?

67. 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?

68. 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

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

70. 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

71. 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

72. 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

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

74. 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

76. Thank you.