THE WHY BEHIND TOBACCO CESSATION IN SOUTHERN ILLINOIS | PATIENT INTERVENTIONS | OFFICE TOOLS | RESOURCES
PATIENT INTERVENTIONS
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MOTIVATIONAL INTERVIEWING
Motivational Interviewing (MI) is a patient-centered counseling technique that focuses on “exploring a tobacco user’s feelings, beliefs, ideas, and values regarding tobacco use in an effort to uncover any ambivalence about using tobacco. Once ambivalence is uncovered, the clinician selectively elicits, supports, and strengthens the patient’s ‘change talk’ (e.g., reasons, ideas, needs for eliminating tobacco use) and ‘commitment language ‘ (e.g., intentions to take action to change smoking behavior, such as not smoking in the home). MI researchers have found that having patients use their own words to commit to change is more effective than clinician exhortations, lectures, for arguments for quitting, which tend to increase rather than lessen patient resistance to change.” ⁶
The goal is to guide the patient to tell you they want to change rather than lecture them that they have to change. Encourage them that cessation is possible and in 2018, 61.7% of adult smokers (55.0 million adults) who ever smoked had quit. ⁸
Studies have found that MI was effective when delivered by primary care physicians and by counselors ⁹ as well as nurses. ¹⁰
MI is based on four key principles:
Express empathy
Develop discrepancy
Roll with resistance
Support self-efficacy
MOTIVATIONAL INTERVIEWING TIPS
Express Empathy
Open-ended questions:
“How important do you think it is for you to quit smoking?”
“What do you think it would be like to stop smoking?”
Reflective listening:
“So you think smoking helps you maintain your weight, how do you feel it affects your heart, lungs and health overall?”
“What do you think you would need to successfully stop smoking?”
Normalize feelings:
“What are your concerns about quitting? Many people worry about managing without cigarettes.”
Support right to choose or reject change:
“I hear you saying you are not ready to quit smoking right now. I’m here to help you when you are ready.”
DEVELOP DISCREPANCY
Voice discrepancy between present behavior and expressed priorities:
“It sounds like you are very devoted to your family. How do you think your smoking is affecting your children?”
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.”
“What do you know about smoking and your family’s health?”
ROLL WITH RESISTANCE
Back off and use reflection when the patient expresses resistance:
“Sounds like you are feeling pressured about your smoking.”
“What do you think will happen if you don’t quit?”
Express empathy:
“You are worried about how you would manage withdrawal symptoms.”
“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.”
Ask permission to provide information:
“Would you like to hear about some strategies that can help you address that concern when you quit?”
SUPPORT SELF-EFFICACY
Help the patient to identify and build on past successes:
“So you were fairly successful the last time you tried to quit, how can we help strengthen that success?”
“What are some past changes you have made about which you feel proud?”
Offer options for achievable small steps toward change:
Call the Illinois Tobacco Quitline (1-866-QUIT-YES) for advice and information."
Read about quitting benefits and strategies.
Change smoking patterns (e.g., no smoking in the home).
Ask the patient to share his or her ideas about quitting strategies.
PATIENTS NOT READY TO QUIT
During Motivational Interviewing keep the 5 R’s in mind if a patient is unsure they can quit: Relevance, Risks, Rewards, Roadblocks, and Repetition. ⁶ The 5R’s help patients to express motivations for quitting tobacco in their own words. It also gives health care professionals the opportunity to address concerns and help meet the patient’s specific needs and objections and boost motivation to finally quit. For patients who are clearly ready to quit tobacco use, utilize the 5A’s model to help them stop using tobacco.
Relevance: Identify motivational factors and encourage the patient to consider why quitting is personally important.
Risks: Discuss side-effects and dangers of tobacco use. Help identify the consequences of continued smoking such as personal and family health risks, financial costs, and example setting for children.
Rewards: Discuss the benefits of stopping. Help patient to identify what the benefits to themselves and their family could include.
Roadblocks: Identify barriers to quitting. Address barriers that led to relapse in past quit attempts and offer suggestions for coping ( see benefits and barriers page)
Repetition: Talk about tobacco cessation (in an abbreviated form) at every visit for patients who smoke. Most tobacco users make several attempts before they succeed in quitting for good.
THE 5 A’s MODEL– ASK, ADVISE, ASSESS, ASSIST, ARRANGE
Starting a conversation about tobacco use can sometimes be difficult or may leave you feeling discouraged by patient response, but as a healthcare provider you have the unique opportunity to influence patient behavior for the better. You can advocate for healthy behaviors, advise patients to quit smoking, support patients as they attempt to quit, and refer patients to medical and community resources that may help them. Though different models exist, the goal is to deliver quick cessation guidance in routine practice. The Public Health Services’ 2008 Clinical Practice Guideline recommends using the 5 A’s model ⁶ Ask, Advise, Assess, Assist and Arrange.
Although longer sessions are more effective, if you can spend:
Up to 3 minutes counseling your patients to quit smoking, you can significantly increase their rates of abstaining from tobacco by 13.4%.
Three to 10 minutes, you can increase their abstention rate by 16.0%
The CDC provides A Practical Guide to Help Your Patients Quit Using Tobacco for simple steps and suggested language that you can use to briefly intervene with patients who use tobacco.
THE BRIEF INTERVENTION MODEL - ASK, ADVISE, REFER
Tobacco users are more successful at quitting with repeated interventions and long-term support. As a provider, your time is limited and you may not be able to address all of the 5 A’s model.
If you have less than 3 minutes to counsel a patient, an alternative to the 5 A’s approach is the Ask-Advise-Refer strategy, which shares the counseling responsibility between providers. Any clinician can initiate the quitting process by asking about tobacco use, advising patients to quit, and then referring patients to other resources who then provide additional assistance and arrange follow-up counseling. This approach has been deemed effective and is a recommended approach in the Clinical Practice Guideline. ⁶
In addition, both of these brief tobacco intervention models are available as a quick reference card.
PARTNERING WITH THE ILLINOIS TOBACCO QUITLINE
Tobacco users who receive advice and resources to quit from their health care provider have higher satisfaction rates. If a health care provider recommends quitting and makes a treatment referral, clients are more likely to make a quit attempt and ultimately stop smoking. Advice from health professionals to quit smoking has increased since 2000; however, four out of every nine adult cigarette smokers who saw a health professional during the past year did not receive advice to quit. ¹² In addition, providers and clinic staff often do not have the time in their busy schedules or the necessary counseling skills to effectively counsel patients on tobacco cessation.
The growing implementation of Fax Referral/ Electronic Fax Referral and Electronic Medical Records (EMR) in primary care may provide an opportunity to more systematically identify and refer smokers to the Illinois Tobacco Quitline (ITQL), thereby increasing the number of smokers who receive help for tobacco dependence.
Setting Up the Referral Program
Referrals give providers an additional opportunity to easily, quickly, and effectively connect clients with individualized tobacco cessation help. Contact the Southern Illinois Tobacco Prevention Partnership to receive Tobacco Treatment Enrollments Forms that are specific to your clinic.
Incorporate the Ask, Advise, Refer Model
Once client consents to being contacted by the Illinois Tobacco Quitline, have the client complete the enrollment form and sign.
Once the form is completed, submit to the Quitline.
The ITQL will call the client and begin the tobacco cessation counseling protocol.
Provider Follow-Up
Providers are encouraged to arrange follow-up appointments to discuss the client’s progress towards cessation.
Important Things to Know
Referrals may ONLY be used if the client gives their written consent.
In order to use Referrals your practice must be a HIPAA Covered Entity (e.g., doctor’s office, dentist’s office, hospital, clinic or agency site).
QUICK TIPS FOR BRIEF INTERVENTION
Ask
Ask patients how often they use tobacco. Identify and document the tobacco use of every patient at every visit. For the current tobacco user, is the user willing to make a quit attempt at this time? For the ex-tobacco user, how recently did he/she quit, and are there any challenges to remaining tobacco free?
Advise
Urge tobacco user to quit and advise those that have tried to try again. Provide each patient who uses tobacco with a clear, strong, and personalized recommendation to quit. Advise in a nonjudgmental manner. Increase patients’ belief in the importance of quitting and their belief in their ability to quit. Personalize the message, relating it to the patient's symptoms, or to economic and social costs, or the impact on family members, e.g. “Your child may have fewer ear infections if you quit smoking.” “Continuing to smoke will make your asthma worse.” Encourage a quit plan to include both counseling & medication
Refer
Refer them to a certified tobacco cessation specialist by completing the enrollment form provided by the Illinois Tobacco Quitline. The Quitline will help the patient create a quit plan; provide brief practical counseling and provide free nicotine replacement therapy (i.e., gum, patches or lozenges) if they do not have insurance coverage. If your office is not set up to refer patients to the Quitline, contact the Southern Illinois Tobacco Prevention Partnership to receive your material to begin referrals.
The goal is to ensure that opportunities are not missed to reach tobacco users who may be ready to quit. If the patient is thinking about quitting or ready to quit tobacco, as a health care professional this model will allow the opportunity to refer a patient to the Illinois Tobacco Quitline.
STAGES OF CHANGE
To select the most appropriate interventions, health care providers can assess a patient's readiness for change. For example, offering a prescription for nicotine replacement to a patient who is not ready to quit in the precontemplation stage is unlikely to be successful. By assessing the patient’s readiness to quit, a provider can then provide the best course for a cessation treatment plan. A provider should encourage the patient during each stage to assist the patient as they work through their quit process to change behavior and work past the triggers.
Stages of Change: Characteristics and Appropriate Actions
| Stage | Characteristics | Appropriate Action |
|---|---|---|
| Pre-contemplation | Reasons to continue smoking dominate No intention to quit | Discuss personalized health benefits of quitting Recognize discouragement of past attempts and provide support when ready |
| Contemplation | Aware of problem Conflicted about behavior Considering change Not ready to apply action | Consider small changes Ask patient to build commitment Increase awareness of cessation aids |
| Preparation | Realizes benefit of making changes Building a commitment to change Ready to act | Begin teaching behavior modification Help patient plan for tempting situations Help to set a quit date and plan Encourage behavioral counseling |
| Action | Taking active steps toward change Recently quit using tobacco | Provide guidance and support Consider pharmacotherapy Refer them to online or phone cessation services, such as the Quitline |
| Maintenance | Initial treatment goals reached Remained off tobacco more than 6 months |
Control relapse and monitor abstinence Recognize any challenge that could lead to relapse |
| Relapse | Starts smoking again Can happen throughout the behavioral change Can be caused by triggers such as emotional stress or distress | Have patience recognize a slip may happen but does not have to be full relapse Encourage patient to identify triggers to smoke and suggest coping strategies Relapse is not failure but another step in the quitting process, quitting may take a few attempts but is possible Reassess readiness to change and enter at appropriate stage. |
A suggested approach to smoking cessation, is provided in the figure below based on the transtheoretical models for reading to change. Progress through these stages is not necessarily linear, and most often cyclical because relapses are almost inevitable in the process of behavioral change. ¹¹
LUNG CANCER SCREENING
According to the U.S. Preventive Services Task Force (USPSTF) lung cancer screening with low-dose computed tomography (LDCT) scans has been found to be effective for certain adults with a history of smoking. Low-dose CT scans may help find lung cancer at an early stage, in turn allowing it to be more treatable. Lung cancer screening is another tool provider can utilize to help encourage patients to maintain their health and consider quitting smoking for good.
As of 2015 according to the Centers for Medicaid and Medicare Services (CMS), a national coverage determination was issued that requires Medicare to cover lung cancer screening for eligible adults. ¹³
Current lung cancer screening eligibility for adults is as follows:
55-77 years of age
Asymptomatic
Have a tobacco smoking history of at least 30 pack-years
Are a current smoker or have quit smoking within the last 15 years
Receive a written order for lung cancer screening with LDCT
In addition, lung cancer screening counseling and shared decision-making visit must be scheduled with the patient to discuss the benefits and risks of the screening. This will help determine if a lung cancer screening is the right course of action for the patient.
In March of 2021, the USPSTF has since updated the recommendations and is awaiting coverage determination from CMS. If approved the updated recommendations would change the age and smoking history as follows:
50-80 years of age
Have a tobacco smoking history of at least 20 pack-years
For more information on lung cancer screening recommendations visit US Preventive Task Force Services
https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/lung-cancer-screening
Medicare Lung Cancer Screening