Using Motivational Interviewing to
Help Your Patients Quit Smoking
Scott M. Strayer, MD, MPH
Associate Professor of Family Medicine
University of Virginia Health System
Disclosures
Scott M. Strayer, MD, MPH disclosed that
he has no financial relationships related
to this presentation.
CS2day is supported by an educational
grant from Pfizer 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 Struggle?
(“strong” endorsements by physicians)
poor self-discipline
poor will-power
not scared enough
not intelligent enough
53.2%
50.0%
36.9%
16.3%
Polonsky, Boswell and Edelman, 1996
Algorithm for Treating Tobacco Use
Does patient now
use tobacco?
See Chapter 2
YES
Is patient now
willing to quit?
YES
NO
NO
YES
Did patient once
use tobacco?
Provide appropriate
tobacco dependence
treatments
Promote motivation
to quit
Prevent relapse*
See Chapters
3A and 4
See Chapter 3B
See Chapter 3C
NO
Encourage
continued
abstinence
a
*Relapse prevention interventions are not necessary in the case of the adult who has not used tobacco for many years.
5
For the Patient
Unwilling 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.
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)
9
Definition of MI
“…a client-centered, directive counseling
method for enhancing intrinsic motivation to
change by exploring and resolving
ambivalence.”
Miller, W.R. & Rollnick, S.(2002)
10
“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
11
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
12
Integrating the Behavioral Theories
13
Decisional Balance
An 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.
14
15
Decisional Balance
Costs of Status Quo
Costs of Change
Benefits of Change
Benefits of Status Quo
Miller, W.R. & Rollnick, S.(2002)
16
The Righting Reflex
The 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.
17
The Spirit of Motivational Interviewing
Collaboration
Confrontation
Evocation
Education
vs.
Autonomy
Authority
“Dance”
“Wrestling”
Miller, W.R. & Rollnick, S.(2002)
18
Motivational Interviewing
Five Key Elements (DARES)
1. Develop discrepancy
2. Avoid argumentation/Roll with
resistance
3. Express empathy
4. Support self-efficacy
19
Step 1: Express Empathy
Acceptance facilitates change.
Skillful reflective listening is
fundamental.
Ambivalence is normal.
Miller, W.R. & Rollnick, S.(2002)
20
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)
21
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
22
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 selffulfilling prophecy.
Miller, W.R. & Rollnick, S.(2002)
23
“Early” Methods to
Enhance Motivation (OARS)
1.
2.
3.
4.
Open-ended questions- get the
patients agenda
Affirm- reinforce statements or
actions that promote change
Reflective listening—ie, listen &
reflect back what you think they’re
trying to say.
Summarize- distill the key
elements of what the patient has
told you in terms of decisional
balance & any change talk.
24
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.
25
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?”
26
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 ___?”
27
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?”
28
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?”)
29
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).
30
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 selfefficacy & intrinsic motivation to change.
31
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?”
32
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)
33
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
Risks
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)
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
34
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 to
the 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
35
For the Patient Unwilling to Quit:
The “5 R’s” (cont.)
Roadblocks
Repetition
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
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
36
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
CS2day
http://cs2day.org/
37
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
38
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!)
39
Persuasion Techniques
•
•
•
•
•
•
•
•
Agree that speaker should make the change
Explain why the change is important
Warn of consequences of not changing
Advise speaker how to change
Reassure speaker that change is possible
Disagree if speaker argues against change
Tell the speaker what to do
Give examples of others (other patients, peers,
celebrities) who have made similar healthy
changes
40
What Did You Think?
41
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.
42
What Did You Think?
43
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 solve
5. Feed back your understanding of the plan
Offer support/sincere encouragement, BUT:
OFFER AS LITTLE ADVICE AS POSSIBLE!
44
What Did You Think?
45