motivating smokers to quit - caiglobal.org...10. art. no.: cd008286. there is no scientific evidence...
TRANSCRIPT
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Rutgers, The State University of New Jersey
Motivating Smokers to QuitMarc L. Steinberg, Ph.D.
Assistant Professor of Psychiatry
Originally Released: August 13, 2013Termination Date: September 12, 2014
Continuing Medical Education (CME) and Continuing Nursing Education (CNE) is available from September 13, 2013 – September 12, 2014.
DisclosureMarc L. Steinberg, PhD, has received unrestricted medical education grants from Pfizer. He is the recipient of a Global Research Award in Nicotine Dependence –an independently-reviewed competitive grants program supported by Pfizer. His presentation will include discussion the drug chantix which is manufactured by Pfizer.
The following people have no relevant financial, professional or personal relationships to disclose:
CME/CNE Program Planner(s):
Robert Cohen, MD (CME Programs)
Marsha Marecki, EdD, WHNP-BC (CNE Programs)
Melanie Steilen, RN, BSN, ACRN (CNE Programs)
CME/CNE Program Reviewer(s):
Robert Cohen, MD (CME Programs)
Melanie Steilen, RN, BSN, ACRN (CNE Programs)
There are no commercial supporters of this activity.
Housekeeping & Logistics
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Introductions/Presenters
Stan Martin, Project Director of CAI, Tobacco Control Training Project. .
Marc L. Steinberg,
Ph.D. Assistant Professor, at Rutgers University - Robert Wood Johnson Medical School in the Division of Addiction Psychiatry
Learning Objectives
Review brief intervention best practices
Participants will be prepared to refer smokers to available smoking treatment resources
Discuss the underlying perspectives of motivational interviewing
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Cigarettes are the only consumer product, that when used as directed, will kill up to half of it’s long-term users.
More deaths are caused each year by tobacco use than by all deaths from HIV, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders… combined.
Empirical Evidence
Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. doi: 10.1111/add.12291
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PharmacotherapiesRisk Ratio
95% CI SampleSize
# of Studies
Bupropion vs. placebo/ control1 1.69 1.53 - 1.85 11,440 36
NRT (all types) vs. placebo/ no NRT2 1.60 1.53 - 1.68 51,265 117
Varenicline (1.0mg 2/d) vs. placebo3 2.27 2.02 - 2.55 6,166 14
Varenicline (low dose) vs. placebo3 2.09 1.56 - 2.78 1,272 4
1. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD000031. 2. Stead LF, Perera R, Bullen C, Mant D, Hartmann-Boyce J, Cahill K, Lancaster T. Nicotine replacement therapy for smoking cessation. Cochrane Database of
Systematic Reviews 2012, Issue 11. Art. No.: CD000146.3. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.:
CD006103.
FDA Approved Medications
bupropion
varenicline
Case Report Data
Review of FDA's Adverse Event Reporting System (AERS)
Case reports for varenicline, bupropion and NRT
Suicidal/self-injurious behavior or depression highest in varenicline group
Not controlled, randomized studies
Re-report of same case report data
Moore TJ, Furberg CD, Glenmullen J, Maltsberger JT, Singh S. Suicidal behavior and depression in smoking cessation treatments. PLoS one,. 2011; 6(11): 1-7.
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Psychosocial approachesRisk Ratio
95% CI SampleSize
# of Studies
Group therapy vs. self-help only4 1.98 1.60 - 2.46 4,375 13
Individual Counseling vs. minimal contact control5
1.39 1.24 - 1.57 9,587 22
Physician advise to quit vs. No advice / Usual care6
1.76 1.58 – 1.95 22,240 26
Motivational Interviewing vs. Brief advice / Usual care7
1.27 1.14 - 1.42 10,538 14
4. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001007. 5. Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD001292. 6. Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD000165. 7. Lai DTC, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD006936.
Poll: What percentage of smokers trying to quit receive counseling as part of their quit attempt?
a) 5%
b) 25%
c) 65%
d) 95%
Attempt without
Counseling
Receive Counseling
Zhu S, Melcer T, Sun J, Rosbrook B, Pierce J. Smoking cessation with and without assistance: A population-based analysis. Am J Prev Med 2000; 18(4):305-311.
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Combined approachesRisk Ratio
95% CI SampleSize
# of Studies
Increased behavioral support + pharmacotherapy
vs.Less or no behavioral support +
pharmacotherapy8
1.16 1.09 - 1.24 15,506 38
Pharmacotherapy + behavioral interventions
vs.Usual care / self-help/brief advice9
1.82 1.66 - 2.00 15,021 40
8. Stead LF, Lancaster T. Behavioural interventions as adjuncts to pharmacotherapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD009670.
9. Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD008286.
There is no scientific evidence that hypnosis helps people to quit smoking.
Some uncontrolled trials are positive, but they aren’t corroborated by RCTs
There is no scientific evidence that acupuncture helps people to quit.
Acupuncture vs. “sham”acupuncture does not reliably find an advantage for acupuncture
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There is no scientific evidence that laser‐therapy helps people to quit.
Claims to work like acupuncture – only without the needles
There is no scientific evidence that e‐cigarettes are safe or effective.
Questions?
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The 5 “A”s
• Ask about tobacco use
• Advise to quit
• Assess willingness
• Assist in quit attempt
• Arrange followup
What you fail to say sends a powerful message too.
http://www.vtquitnetwork.org/
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https://vermont.quitlogix.org/
http://www.vtquitnetwork.org/all-locations
Questions?
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Motivational Interviewing Myths
NOT based on the transtheoretical model of change
NOT a specific technique
NOT easy to learn
NOT a panacea for every clinical challenge
Pragmatic definition of MI
Motivational Interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change.
- Miller & Rollnick, 2012
Ambivalence
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Definition of MI
MI is a collaborative, goal oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
- Miller & Rollnick, 2012
Definition of MI
MI is a collaborative, goal oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.
- Miller & Rollnick, 2012
Underlying perspective of MI
Partnership Dancing, not wrestling
Acceptance Absolute worth, Accurate Empathy, Affirmation, Autonomy Support
Evocation Assumes patients already have motivation and resources within
Compassion Pursuit of best interest for your patient
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Spirit of MI
Open Ended Questions
Affirmations
Reflective Listening
SummarizingReadiness Ruler
Decisional Balance
Develop Discrepancy
Stages of Change
Prochaska & DiClemente (1983) JCCP, 5, 161-173
Precontemplation
Contemplation
Preparation
Action
Maintenance
Permanent Exit
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Stages of Change
Prochaska & DiClemente (1983) JCCP, 5, 161-173
Precontemplation
Contemplation
Preparation
Action
Maintenance
Permanent Exit
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Questions?
How do I get started?
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Four Processes in MI
Planning
Evoking
Focusing
Engaging
Engaging Skills
“Micro‐skills”
Open questions
Affirming the client
Reflective listening
Summarizing
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Open Questions
Difficult to give a short answer
Open vs. Closed Questions:
Closed: Are you worried about smoking?
Open: What worries you about smoking?
Closed: Do you think it’s important to go to quit smoking?
Open: Why might it be important to quit smoking?
Affirmations
Show appreciation / validate strengths
Should be genuine
Builds rapport / reduces negativity
“You’re really working hard on this.”
“You really are a good mom.”
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Reflective Listening
Allows patient to feel heard
Allows provider to confirm perceptions
Simple, declarative statement
“Everyone wants you to quit, but it’s hard to imagine your life without cigarettes”
“You’d like to quit – you’re just afraid of the withdrawal symptoms”
Summarizing
Lets client know you heard all sides
Allows you to present the discrepancy “and” not “but”
Good for focusing or transitioning
Emphasize crucial points (“guiding”)
“What else?”
Questions?
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Four Processes in MI
Planning
Evoking
Focusing
Engaging
Open Questions
Engaging: How have things been?
Focusing: What are you hoping will be different?
Giving Advice / Information
ELICIT permission
PROVIDE advice, instruction, concern
ELICIT reactions
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Four Processes in MI
Planning
Evoking
Focusing
Engaging
Open Questions
Engaging: How have things been?
Focusing: What are you hoping will be different?
Evoking: Why might you want to stop…?
Self‐perception theory
We learn about our beliefs and attitudes by hearing ourselves talk.
Moral: Let patients make the argument for change.
Bem, D. J. (1967). Self-Perception: An Alternative Interpretation of Cognitive Dissonance Phenomena. Psychological Review, 74, 183-200.
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Questions?
Recognizing and Reinforcing“Change Talk” and Readiness
DesireDesire
AbilityAbility
ReasonsReasons
NeedNeed
CommitmentCommitmentBehaviorChangeBehaviorChange
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Commitment Language
Friday is my quit date, and I’m never going
to smoke again.
I’m going to quit smoking soon.
I’m going to try to quit smoking.
I’d like to quit smoking.
Why does eliciting change talk and commitment language help?
Self‐perception theory
We learn about our beliefs and attitudes by hearing ourselves talk.
Eliciting “change talk” increases commitment.
Eliciting “sustain talk” decreases commitment.
Moral: Let patients make the argument for change.
Bem, D. J. (1967). Self-Perception: An Alternative Interpretation of Cognitive Dissonance Phenomena. Psychological Review, 74, 183-200.
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Eliciting Change Talk: Strategies
Use open-ended questions
Explore client goals and values
Querying extremes
Looking forward
Other’s concerns
Responding to Change Talk
Elaboration
Affirm
Reflect
Summaries
Questions?
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Tools for Eliciting Change Talk
Decisional Balance
Importance-Confidence-Readiness Ruler
Decisional Balance
Enhances credibility and rapport
Always start with the “not-so-good things”
Follow-up with open-ended questions
Offer a summary statement of both sides
Use the summary as a motivational tool
“Not So Good Things”
about smoking
“Good Things”
about smoking
Decisional Balance
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“Not So Good Things”
about smoking
“Good Things”
about smoking
Alternative ways to get the “Good Things”
Decisional Balance
ICR ‐ Importance
How important is it for you right now to quit smoking? On a scale of 0 to 10, what number would you give yourself?
0 ………………………………………………………………….. 10
not at all extremely
important important
ICR ‐ Confident
If you did decide to change, how confident are you that you could quit smoking?
0 ………………………………………………………….. 10
not at all extremely
confident confident
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ICR ‐ Ready
How ready are you to quit smoking right now?
0 ………………………………………………………….. 10
not at all extremely
ready ready
When using ICR Ruler…
Remember:
Self-perception theory
Low number = sustain talk
High number = change talk
Express empathy – changing is hard!
ICR Ruler
How important / confident …..?
On a scale of 0 to 10, what number would you give yourself?
High #: “Tell me more”
Low #: “Why not zero?”
What would it take to move you from an X to a (X+1)
What can I do to help you feel more confident?
0 ………………………………………………………………….. 10not at all extremely
important /confident important /confident
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Questions?
Four Processes in MI
Planning
Evoking
Focusing
Engaging
Open Questions
Engaging: How was your week?
Focusing: What are you hoping will be different?
Evoking: Why might you want to stop…?
Planning: Where do we go from here?
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Key Questions
“So, what’s next?”
“What do you make of all this?”
“Where do we go from here?”
Remember “E – P – E”
ELICIT permission
PROVIDE advice, instruction, concerns
ELICIT reactions
Offer a menu of options
Eliminates “skeet shooting”
Maximizes patient autonomy/choice
Start simple, and avoid jargon
“Which option seems most possible?”
“Where’s the best place to start?”
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Treatment Goals
Set a quit date – abrupt cessation
Set a quit date – reduction-to-quit
Flexible quit date1
Reduction of more than 50% is associated with increased future quit attempts
1Hughes JR, Russ CI, Arteaga CE, & Rennard SI. Efficacy of a flexible quit date versus an a priori quit date approach to smoking cessation: a cross-study analysis. Addict Behav. 2011 Dec;36(12):1288-91.
Smoking reduction concerns
Still need concrete goals
No level of safe smoking
Not proven reduce harm
Compensatory smoking
Withdrawal symptoms without meds
Questions?
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ConsolidatingClient Change
Eliciting Commitment
“Is this what you want to do?”
Make it as public as appropriate
Recognize ambivalence
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Conclusions
Ask all patients about smoking at every visit
Assist those who are willing to try Prescribe FDA approved medications Provide practical support Refer (phone, online, in-person)
Motivate those who are currently unwilling Use spirit of motivational interviewing to
increase readiness to quit
Thank you!
I appreciate your time and attention. I hope this was helpful!
Marc L. Steinberg, [email protected]