Focus on Prevention: Motivating Patients to Change

Question 1

Behavior change stages

Answer 1

1) Precontemplation Stage
2) Contemplation Stage
3) Preparation Stage
4) Action Stage

–Motivational interviewing can be very effective
This involves incorporating empathy and reflective listening with key questions so that the provider is simultaneously patient-centered and directive

Question 2

1) Precontemplation Stage:

Answer 2

Change is not considered by the patient

Patient is uninterested, unaware, or unwilling to make a change

Question 3

2) Contemplation Stage

Answer 3

Change is being considered
Barriers are being assessed
Benefits and costs of behavior are weighed

Question 4

3) Preparation Stage

Answer 4

Preparing to make a specific change
Possibly experimenting with small changes
Switching brand of cigarettes
Drinking less (alcohol)

Question 5

4) Action Stage

Answer 5

Taking a definitive action to change

Any action taken by patients should be praised

Question 6

Questions in the Precontemplation Stage

Answer 6

Goal: patient will begin thinking about change
“What would have to happen for you to know that this is a problem?”
“What warning signs would let you know that this is a problem?”
“Have you tried to change in the past?”

Question 7

Questions in the Contemplation Stage

Answer 7

oal: patient will examine benefits and barriers to change
“Why do you want to change at this time?”
“What were the reasons for not changing?”
“What would keep you from changing at this time?”
“What are the barriers today that keep you from change?” What might help you with that aspect?
“What things have helped in the past?”
“What would help you at this time?”
“What do you think you need to learn about changing?”

Question 8

Relapse from changed behavior

Answer 8

Relapse is common during lifestyle changes.
When relapses occur, support the patient and re-engage their efforts in the change process.
Focus on the successful part of the plan.
Inform them they have learned something new about themselves.

Question 9

Benefits of smoking cessation

Answer 9

Reduces the risk of death, myocardial infarction and stroke for both individuals with and without a prior history of cardiovascular disease.
Tobacco cessation is associated with a reduction of cancer risk.
Improves chronic obstructive pulmonary disease symptoms in patients with the condition.
Reduces the risk of diabetes after several years of abstinence.
Women smokers who quit smoking by age 35 add about 3 years to their life expectancy, men add more than 2 years to theirs.
Can also increase life expectancy for those who stop after the age of 65.

Question 10

Benefits of talking about smoking cessation

Answer 10

While over 70% smokers see a physician each year, only 20% receive any medical advice to quit.

–> If a clinician advises a smoker to quit, the smoker is 1.6 times more likely to attempt quitting.

Almost 40% of smokers attempt to quit each year, but only 4% are successful

Question 11

Tobacco counseling recommentations

Answer 11

Adults Age ≥18 Years
Ask about tobacco use. Provide tobacco cessation interventions to those who use tobacco products.
Pregnant Women of Any Age
Ask about tobacco use. Provide augmented pregnancy tailored counseling for women who smoke.

Question 12

Screening for tobacco use

Answer 12

All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status or the use of other reminders systems such as chart stickers or computer prompts, significantly increase rates of clinician intervention. (Strength of Evidence = A)

Question 13

Physician advice to quit smoking effectiveness

Answer 13

All physicians should strongly advise every patient who smokes to quit because evidence shows that physician advice to quit smoking increases abstinence rates. (Strength of Evidence = A)

Question 14

Common tools for smoking cessation

Answer 14

5 A’s:
Smoking Cessation Strategy for Routine Practice.
Brief office encounters with patients that smoke can be patterned on the 5A’s

5 R’s:
Abbreviated Smoking Cessation Counseling.
Can be incorporated into interventions in order to enhance a patient’s motivation to quit.

Question 15

5 A’s of smoking cessation

Answer 15

Ask: Inquire about smoking status
Document tobacco use – Every patient – Every visit
Indicate those patients who are not users

Advise: Firmly urge smokers to quit

Assess: Determine willingness to quit, may use Stages of Change

Assist: Counsel, see 5 R’s. If sets quit date, begin pharmacotherapy

Arrange: Follow-up by phone or office visit after quit date

Question 16

5 R’s of smoking cessation
—> For tobacco users who do not want to quit now, interventions incorporating the 5 R’s can be used to increase the likelihood that they will decide to quit.
Tobacco users should address each topic in their own words.

Answer 16

1) Relevance: Encourage the patient to indicate why quitting is personally relevant.

2) Risks: Ask the patient to identify potential negative consequences of tobacco use.
Emphasize that low-tar/low-nicotine cigarettes or use of other forms of tobacco will not eliminate risks

3) Rewards: Ask the patient to identify potential benefits of stopping tobacco use.

4) Roadblocks: Ask the patient to identify barriers or impediments to quitting
Provide treatment that could address barriers

5) Repetition: The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting.

Tobacco users who have failed with past quit attempts should be told that most individuals make repeated quit attempts before becoming successful.

Question 17

Opportunity for attack

Answer 17

Smokers are more liable to quit during acute episodes of inpatient or outpatient illness

Question 18

What to recommend to Pt’s that are quitting smoking

Answer 18

Clinicians should encourage all patients attempting to quit to use effective medications for tobacco dependence treatment, except where contraindicated or for specific populations for which there is insufficient evidence of effectiveness (i.e., pregnant women, smokeless tobacco users, light smokers, and adolescents). (Strength of Evidence = A)

Question 19

First line medications for smoking cessation

Answer 19

Bupropion SR
Nicotine gum
Nicotine inhaler
Nicotine lozenge
Nicotine nasal spray
Nicotine patch
Varenicline (Chantix)

Question 20

Two types of counseling and behavioral therapies result in higher abstinence rates:

Answer 20

(1) providing smokers with practical counseling (problem solving skills/skills training), and (2) providing support and encouragement as part of treatment. These types of counseling elements should be included in smoking cessation interventions. (Strength of Evidence = B)

Question 21

Practical counseling components to quit smoking

Answer 21

• Recognize danger situations: Identify events, internal states, or activities that increase the risk of smoking relapse
• Develop coping skills
• Provide basic information about smoking and successful quitting

Question 22

Supportive treatment components to quit smoking

Answer 22

• Encourage the patient in the quit attempt
• Note that 1/2 of all people who have ever smoked have now quit
• Communicate belief in patient’s ability to quit
• Communicate caring and concern
• Directly express concern and willingness to help
• Encourage the patient to talk about the quitting process
• Ask about reasons for why the patient wants to quit
• Ask about concerns patient has about quitting

Question 23

Combining Counseling and Medication

Answer 23

The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, whenever feasible and appropriate, both counseling and medication should be provided to patients trying to quit smoking. (Strength of Evidence = A)