The Five R’s for Smoking Cessation: Helping the Smoker Who is Not Ready to Quit August 5, 2008

1. Conference Line: 866-846-3997 • Passcode: 910303# • Objectives: • Explain the CCGC Guideline for Tobacco Cessation and Secondhand Smoke Exposure • Identify resources and tools providers in Colorado have available to help their patients quit using tobacco and reduce secondhand smoke exposure. • Illustrate strategies providers can use to help their patients quit using tobacco and to reduce secondhand smoke exposure. • Completing the following evaluation is also your request for credit form to enable CFMC to produce certificates. The link will be emailed out to you an hour after the presentation. • CME Evaluation Link: http://www.surveymonkey.com/s.aspx?sm=W3XmRc9eXvdPEVmmnHwUpw_3d_3d The Five R’s for Smoking Cessation: Helping the Smoker Who is Not Ready to Quit August 5, 2008

2. The 5 R’s for Smoking Cessation:   Helping the Smoker Who is Not Ready to Quit Dr. Heather LaChance Assistant Professor of Medicine National Jewish Health/University of Colorado Denver

3. Goals for Today’s Training • Quick overview on Stages of Change • Review the 3 important Motivational Intervention skills –crucial when dealing with unmotivated smokers • Discuss the 5 R’s model • Present and discuss case scenarios

4. Stages of Change PREPARATION Pre- Contemplation AMBIVALENT ACTION RELAPSE MAINTAIN Permanent Exit Pre-Contemplation = Not yet even thinking about behavior change Contemplation = Ambivalent and thinking about change Preparation = Decision that change is necessary and possible Action = Actively working toward behavior change Maintenance = Sustaining new behavior Relapse = PART of change cycle and often several before maintenance Transtheoretical Stage Model

5. Ambivalence is Normative • In a study of active smokers it was shown that the distribution of smokers fell in the first three Stages of Change. • These findings have been replicated across three large representative samples: • 40% of smokers are in the Pre-contemplation stage. • 40% are in the Contemplation stage. • 20% are in the Preparation stage. *About 70-80% of smokers are ambivalent to make a change (Velicer, et al., 1995)

6. Psychological Reasons Smokers Are Unwilling To Quit • Demoralization/Fear: Fear of failure Fear of discomfort (irritability, cravings, fatigue) Fear of never being able to smoke again • Loss of Primary Coping Method Dealing with anger, stress, anxiety, etc. • Emotional Attachment: Tobacco can feel like a ‘friend’ when lonely or upset • Self- Rewards: Smoking can motivate and reward (even everyday tasks) • Alienation: Others who use tobacco may reject them, minimize, or discount their desire or efforts to quit

7. Where is the Magic Bullet? • Many providers think if they convincingly explain the reasons a tobacco user should quit, the person will somehow see they should quit. • This can actually trigger more resistance. • There a things providers can do to improve motivation or hinder it but…. • THERE IS NO MAGIC BULLET.

8. Improving Motivation • The first goal in this type of counseling is to improve SELF-EFFICACY and HOPE that when and if they want to, they can do it! • The second goal is to have a conversation focused on “what if…” rather than about how to quit or setting a date.

9. Crucial Counseling Skills • There are KEY COUNSELING skills that are necessary, especially when dealing with people who are defensive, shut-down, or unmotivated to quit. • The goal is to create a tone of EXPLORATION not overly didactic and not overly directive. Compassion drives Change.

10. Skill #1 Reflective Listening • 1. Form a reasonable guess as to the underlying or unspoken meaning. • 2. Rephrase what the person has just said, in a statement, not in a question. • 3. Reflect back to the person what you hear them saying. “Sounds like you’ve made some serious attempts…” “You sound like you’ve done some thinking about this...” • You know your reflection is right when the person says “Yes” “Exactly” “Yeah” etc.

11. Skill #2: Ask Meaningful Questions • Use questions that generate self-reflection combined with affirmations to propel talk about change forward • Research shows that when physicians/treatment providers simply ASK about behaviors, it can lead to a 30% increase in patients attempts to quit smoking.

12. Ask Open-Ended Questions • Open questions are open-ended.. Evoke thought. • They start with:WHAT...?, HOW..?, WHEN..?, WOULD YOU…?, or TELL ME MORE… • Open questions encourage clients to take responsibility and think about what they are feeling and/or want: What concerns you the most?How might you change that?How could things be different now?How would you want to work on this skill more? • Open questions engender exploration and minimize defensiveness.

13. Closed Questions • Closed questions force a yes or no answer. • Closed questions are usually about making decisions or judgment. • Closed questions begin with: • ARE you…? DO You…? DON’T You….? and WHY are you..? WHY aren’t you..? • Can shut down the conversation, lead to defensive answers, and prevent the patient being in the driver’s seat.

14. Asking Quality Questions Open / better: • What are your thoughts about quitting at this time? • How would you feel differently if you were to quit? • Your blood pressure has gone up, what do you make of that? • What is the hardest thing for you in in thinking about quitting? Closed: • Why don’t you want to quit smoking? • Don’t you want to feel better? • Your blood pressure has gone up, why is that do you think?

15. Ambivalence • When talking to someone who doesn’t want to quit – remember everyone has ambivalence…. • There are moments where the tobacco user thinks “I need to quit…” or “I wish quitting was easy..” • Most every tobacco user has some degree of ambivalence • It is about generating a conversation that helps the person feel comfortable (not judged) so they can share their ambivalence… and you can increase it.

16. What are the 5 R’s? • Once you have identified a tobacco user who does not want to quit, the PHS Clinical Guidelines suggests using a strategy of the 5 R's: • Relevance • Risks • Rewards • Roadblocks • Repetition

17. elevance R • Relevance = create a conversation that is personally important to the smoker. • The goal is: “What is important to this person?” • For one tobacco user, a concern might be about their pet’s health status, over and above their own health. • For another tobacco user, it might be fear of aging. • For another, it might be concern for their children or grandchildren who might will grow up to become a tobacco user.

18. elevance R • Explore personal motivators –  what are the patient's opinions and attitudes?  family or social situation (i.e., children or grandchildren),  what concerns them?  age, gender and other important patient characteristics • What won’t work: • Simply asking “Why might you want to quit?” {closed question}

19. elevance R • Opening the conversation: • Enlist willingness to even talk about it.TxP: “I see here in your medical chart you smoke…”Pt: “yeah… I know, I know, it’s bad…” {looks down sheepishly}{don’t jump right to “So, do you want to quit?”}TxP: “It’s OK, quitting is very hard and people can only quit when they feel ready and committed to it. But, if it’s OK with you, I’d just like to talk to you a little bit about smoking and get an idea of some of your thoughts. Would that be OK?”

20. elevance R • Enlist willingness to engage: Pt: “Look, I already know what you are going to say, that I must quit and I’m going to die if I don’t right?” {defensive, puts TxP on the defensive}TxP: Well, that wasn’t exactly what I was going to say… I was actually more interested in your thoughts and what you are feeling at this time. I’d like to understand your perspective rather than give you a big lecture. {smile} Would it be OK if we talked for a little bit so I can understand your feelings and where you are coming from?”  Be non-threatening – come in through the back door.

21. elevance R • Decisional Balance: Ask about the pros and cons of use • TxP: “So, what do you like about smoking?” -knowing what someone likes about smoking helps you understand the role & valence it plays in their life • “Oh I don’t even like it… it’s just a habit.” vs. • “I have a stressful life and it’s the one good thing I have.” • “I guess it helps when I feel down or bored…” • USE REFLECTIVE LISTENING to keep the conversation about exploring rather than judging or advice.

22. isks R • Risks = Ask the individual about potential risks they see in smoking/ tobacco use. • Keep Relevance in mind, use OPEN questions: • “So what concerns you about your smoking?” • “What thoughts have you had about your health and smoking?” • “What do fear the most?” • “What about your family (or pets)…. What do worry about for them?” • What have you noticed about your health compared to 10 years ago?”

23. isks R • Examples of health-related risks are: • Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, wrinkling/aging, and increased serum carbon monoxide. • Long-term risks: Heart attacks and strokes, limb amputation due to clotting, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability and need for extended care. • Environmental risks: Increased risk of lung cancer and heart disease in spouses, higher rates of smoking in children of tobacco users, increased risk for low birth weight, infant w/ cleft lip or palate, Sudden Infant Death Syndrome, asthma, middle ear disease and respiratory infections in children of smokers.

24. isks R • Examples of personal risks are: • Acute risks: Feeling slighted socially (‘like an outcast’), comments from children or grandchildren about smell, inability to breathe limits activity, less physical intimacy if non-smoking partner, if single much greater difficulty in finding partner (75% of population is non-smoking), • Long-term risks: pets and other family members at risk for cancer, lung disease or stroke, de-conditioning leading to less pleasurable lifestyle, loss of quality of life with any health condition • Environmental risks: Home and car smelling, frequent work breaks decrease productivity, feeling must hide at work, spit tobacco in home/car is unappealing

25. isks R • Remember to reflect any concerns someone says… this allows the individual to hear their own thoughts out loud… • “So it sounds like your children (or grandchildren) have told you that smoking makes you ‘stinky.’ That must have stung a bit... It seems to me that you want to be a positive role model for them. What do you think it would mean to them if you were able to quit? • So you’ve had some concerns about whether smoking might hurt your little dog. You sound like a responsible owner! Second-hand smoke is very potent and with a small animal, the risks to their lungs can be even greater; you are exactly right! What are your thoughts about that?

26. isksandelevance R R • Although health care providers might be most concerned about a patient’s health – for example, high blood pressure and smoking – it is important to find out what motivates that person… • -it could be a pet or child more than their own health. • -it could be knowing they are wrinkling/aging faster. • -it could be their spouse’s health. • -it could be financial strain from smoking/tobacco use.

27. ewards R • Rewards =Ask the patient to think about the benefits from quitting. • “How might you feel about yourself if you quit?” • “Let’s assume that magically you woke up a non-smoker tomorrow. What would be different in your life / for you?” • “How might your children/spouse feel if you quit?” • “How much money do you think you’d save if you quit?”

28. ewards R Common Rewards: • Improved health. • Food will taste better. • Improved sense of smell. • Save money. • Better self-image. • Home, car, clothing, breath will smell better. • Can stop worrying about quitting. • Set a good example for children. Have healthier babies and children. • Eliminate worry about exposing others to smoke. • Feel better physically. Perform better in physical activities. • Reduced wrinkling/aging of skin.

29. oadblocks R • Roadblocks = the personal psychological obstacles that prevent a person from quitting. • What fears or concerns do you have about quitting? • What is preventing you from trying to quit? • What do think quitting would be like? • What have your other quit attempts been like?

30. oadblocks R Typical Roadblocks: • Withdrawal symptoms (cravings & irritability) • Stress (don’t know relaxation or self-calming techniques ) • Fear of failure (avoiding self challenge) • Weight gain • Lack of support (partner, friends or family will reject them) • Enjoyment of tobacco (not sure how to self soothe orfind more enjoyable rewards) • Depression (or feeling lonely, like they’ve lost a friend)

31. oadblocks R Address Roadblocks: Withdrawal & Medication • Most people are unaware of how helpful current medication therapies are… explain how medications can double to triple success rates and reduce cravings and alleviate withdrawal symptoms. • In a recent study, Shiffman et al (2008) found 66% of people agreed that “stop smoking products with nicotine are just as harmful as cigarettes” or were unsure if this was true! Moreover, these folks were less likely to use NRT as a result. • Explain that nicotine is NOT the chemical in tobacco linked to cancer, stroke, heart disease, etc. The combination of dangerous additives and carbon monoxide leads to serious cell damage and respiratory illness.

32. oadblocks R Address Roadblocks: Stress and Relaxation • Many people report high levels of stress as a major obstacle to quitting. • Smoking/tobacco does not actually reduce stress it increases it; nicotine and carbon monoxide increase blood pressure thereby putting more strain on the heart, decreasing oxygen circulation, and harming cells’ ability to heal during stress. • What’s needed: new ways to learn how to cope with stress: meditation, progressive muscle relaxation, yoga, effective breathing techniques – all have been found to calm the central nervous system and help the body respond to stress more effectively.

33. oadblocks R Address Roadblocks: Fear of Failure • Whether people state it out loud or not, it is generally safe to assume most smokers and tobacco users fear failure. • Most individuals have tried to quit and repeatedly failed. • REFRAME FAILURE: • How might it feel if you were able to overcome this? • Most smokers need many quit attempts to be successful. In fact, research shows that it’s the people who make more quit attempts that are the successful ones – failure seems to be necessary in quitting.

34. oadblocks R Address Roadblocks: Weight Gain • Many people, and woman especially, report fearing weight gain as a barrier to quitting. • Explain that, on average, weight gain is minimal – between 5-10 lbs • Medications have been found to prevent weight gain during quitting process (such as bupropion with NRT). • Exercise and modification of eating can prevent serious gain. • Additionally, small amount of weight gain is preferable to significant health issues associated with tobacco use.

35. oadblocks R Address Roadblocks: Fear of Failure • Whether people state it out loud or not, it is generally safe to assume most smokers and tobacco users fear failure. • Most individuals have tried to quit and repeatedly failed. • REFRAME FAILURE: • How might it feel if you were able to overcome this? • Most smokers need many quit attempts to be successful. In fact, research shows that it’s the people who make more quit attempts that are the successful ones – failure seems to be necessary in quitting.

36. oadblocks R Address Roadblocks: Lack of Social Support • Increasing social support in the smoker’s environment increases long-term cessation by 50% (Fiore et al., 2000). • If smoker reports that they are single OR family/partner are not supportive of quitting, find out if there are any other resources. • “Who do you know might support you if you quit?” • Sometimes children or friends who have quit can help. • “When you are ready, the QuitLine provides support –trained coaches who are very supportive. You can call them whenever you are having difficulty.”

37. oadblocks R Address Roadblocks: Enjoyment of Tobacco • Validate for the smoker/tobacco user that smoking is enjoyable. Although this seems odd, it diffuses the argument. • TxP: “Yes, it’s true, smoking is very enjoyable. So, when you are ready to quit, it will be important to find other things that you enjoy. Many smokers say that once they’ve quit, they are surprised by the new things they find enjoyable.” {leave it vague} • Pt: “Like what?” • TxP: “Well, what do you think you might find enjoyable?”

38. oadblocks R Address Roadblocks: Depression/Loneliness • Depression, loneliness, anxious and/or feeling emotional can also be lumped in under self-reported ‘stress’. • Although depression and other mental health issues have been found to lower quitting success rates, these issues do not necessarily mean someone cannot quit. • If someone discloses depression/anxiety, refer patient to work with a psychologist or mental health professional– even if the person is not yet ready to quit. • Comprehensive treatment plan is needed that includes Cognitive Behavioral Therapy in conjunction with relaxation training and smoking cessation planning.

39. epetition R • Repetition is necessary to facilitate change. • We all learn from repetition. • Have many conversations about tobacco use with smokers/tobacco users - use an open, nonjudgmental, and exploring tone. • “So the last time we talked, I remember you were concerned about your blood pressure and coughing more than you used to. At the same time, you mentioned you were worried about gaining weight and finding other enjoyable things to do when you quit. What thoughts have you had about that since your last appointment?”

40. Scenario 1: Mac • Mac is a 57 year old veteran who has recently moved here from Phoenix to live with his daughter and grandchildren in Adams County affordable housing. • He has smoked a pack to 1 ½ packs a day since he was 17 when he entered the military. • He has been seen 3 times (by three different providers) at the clinic in the past 5 months for bronchitis and/or complications related to his hip. • When you check his chart you see your colleagues have made a notation that Mac is a tobacco user in transcribed notes and his social history, but no further documentation has occurred related to his nicotine addiction. • When asked about quitting nicotine, Mac breaks eye contact, looks uncomfortable, and becomes unresponsive.

41. Mac & 5 R’s • Relevance: This man moved across country to be with this daughter and grandchildren. This is a motivation. Because he’s looked uncomfortable in the past, – go through the backdoor. • What types of things do you do with your grandchildren? • I notice in your chart you smoke, what are your thoughts right now about your smoking? • How might your family motivate you to think about quitting? • Risks: What concerns do you have about your smoking for them? For yourself… (i.e., being around for them…)? • Rewards: How might it feel to be a non-smoker around your grandchildren? {build self-efficacy}

42. Mac & 5 R’s • Documentation: Since it is hard to provide Repetition without adequate follow-up without enough information in a patient’s chart. It is always good to write down which of the 5 R’s you discussed and ultimate result of your conversation for the next provider. • Rewards: Money. • “Mac, did you know that you smoke about 546 packs of cigarettes a year? How much do you think that ends up costing? (answer: $2184) • What kinds of things do you think you could do with $2,200 more in your pocket per year? • I’ve known some smokers who quit and put the money they spend each day on cigs in a big jar and watch the money accumulate. What might that be like for you?

43. Avoid closed questions • “Don’t you want to make your grandkids proud of you?” • “Do you think that your smoking might have an impact on them?” • “Don’t you want to have more money in your pocket?” • What does this do…? • -shuts people down and leads to guilt/defensive answers • -leading questions prevent the person from thinking

44. Scenario 2: Pat • Pat is a 40ish medical assistant for a primary care physician’s office. She smokes one to two packs of cigarettes a day. • She reports that her colleagues in the office support her quitting, sometimes to the point of nagging. • She has had multiple quit attempts over the past 10 years. Her longest quit attempt (18 months ago) was approximately three months and reports that the patch made her “sick.” • When asked why she smokes she is very clear that it is her way of relieving stress. • When approached with the opportunity to be prescribed Chantix she states that “it is too expensive, and my daughter is getting married in May and I don’t have any money.”

45. Pat & 5 R’s • Relevance: Pat has negative social support – people nag her about it. REFRAME this as caring. • “Pat, research shows that negative social support (nagging) actually leads to improved quitting success. So, although it is annoying, you are lucky to have friends who care about you and want to help you kick the habit. I’m curious, what would it be like to socialize with these co-workers as a non-smoker?” • Rewards: “How might it be for you to be a non-smoker in your role as a medical assistant? What would the benefits be?”

46. Pat & 5 R’s • Rewards: “Pat, I see hear from your chart that you have made multiple quit attempts. Although it might seem discouraging, this is actually great news! Research shows that people who repeatedly try to quit are the ones who actually end up successful!” {build self-efficacy} It is especially impressive that you were able to quit for 3 months! How were you able to do it, what worked for you?”

47. Pat & 5 R’s • Roadblocks: Medication • Pat quit for 3 months (not clear if she was on or off the patch during that quit attempt?). If she reports the patch and made her “sick,” I would double check that she used the patch correctly. Was she on the 21mg the entire time or did she step down correctly? • Also, sometimes people confuse withdrawal symptoms with patch side-effects. Assess what exactly happened when she got sick. • Roll with Resistance: “Pat, I realize you might not be ready to quit yet. But there are other medications other than the patch that have been found to really help with withdrawal symptoms. When you are ready, we can talk more about them.”

48. Scenario 3: Jerry • Jerry is a 45 year old restaurant owner who is receiving outpatient treatment for alcohol addiction. • He has recently been diagnosed with diabetes. • When presented with the health consequences related to tobacco use he becomes sullen and anxious. • He is making very good progress with recovering from alcohol dependence and sees tobacco use as something he can deal with later when he has been sober for much longer. Jerry states, “This is my last vice and it doesn’t hurt anybody; I will deal with it later; I have enough to do with my recovery program and sticking myself (to check my blood sugar) 4 times a day.”

49. Jerry & 5 R’s • If Jerry became sullen and anxious after “being presented with the health consequences related to tobacco use” – it is possible that it came across as too didactic. Remember to use Relevance. • “Wow, Jerry, it is fabulous that you have remained abstinent from alcohol! This really tells me that when you are ready, you will be able to give up tobacco too. Did you know that in a large research study, they found that people in alcohol dependent treatment who also quit smoking did better both in remaining abstinent from alcohol and in quitting smoking? Because alcohol and smoking often go hand-in-hand, staying away from both can actually help you. What do you make of that?”

50. Jerry & 5 R’s • Rewards: • What do you think you could gain from quitting smoking {or tobacco use}? • How might you feel about yourself? • How might this help your diabetes do you think?