Motivating Smokers to Quit

Transcription

1 Motivating Smokers to Quit Marc L. Steinberg, Ph.D. Assistant Professor of Psychiatry Originally Released: August 13, 2013 Termination Date: September 12, 2014 Continuing Medical Education (CME) and Continuing Nursing Education (CNE) is available from September 13, 2013 September 12, Rutgers, The State University of New Jersey Disclosure Marc 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 Polls Live questions Typed questions/chat Raise hand Tech Difficulties

2 IMPORTANT NOTICE This GotoWebinar/GotoMeeting service includes a feature that allows audio and any documents and other materials exchanged or viewed during the session to be recorded. By joining this session, you automatically consent to such recordings. Please note that any such recordings may be subject to discovery in the event of litigation. 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 2

3 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 Hartmann-Boyce J, Stead LF, Cahill K, Lancaster T. Efficacy of interventions to combat tobacco addiction: Cochrane update of 2012 reviews. doi: /add

4 Pharmacotherapies Risk Ratio 95% CI Sample Size # of Studies Bupropion vs. placebo/ control , NRT (all types) vs. placebo/ no NRT , Varenicline (1.0mg 2/d) vs. placebo , Varenicline (low dose) vs. placebo , Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD 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.: CD Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 4. Art. No.: CD 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):

5 Psychosocial approaches Risk Ratio 95% CI Sample Size # of Studies Group therapy vs. self-help only , Individual Counseling vs. minimal , contact control 5 Physician advise to quit vs. No , advice / Usual care 6 Motivational Interviewing vs. Brief , advice / Usual care 7 4. Stead LF, Lancaster T. Group behaviour therapy programmes for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD Stead LF, Bergson G, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD Lai DTC, Cahill K, Qin Y, Tang JL. Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews 2010, Issue 1. Art. No.: CD Poll: What percentage of smokers trying to quit receive counseling as part of their quit attempt? a) 5% b) 25% c) 65% d) 95% Receive Counseling Attempt without 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):

6 Combined approaches Increased behavioral support + pharmacotherapy vs. Less or no behavioral support + pharmacotherapy 8 Risk Ratio 95% CI Sample Size # of Studies , Pharmacotherapy + behavioral interventions vs. Usual care / self-help/brief advice , Stead LF, Lancaster T. Behavioural interventions as adjuncts to pharmacotherapy for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD Stead LF, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD 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 6

7 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? 7

8 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. 8

9 Questions? 9

10 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 10

11 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 11

12 Open Ended Questions Develop Discrepancy Decisional Balance Spirit of MI Affirmations Reflective Listening Readiness Ruler Summarizing Stages of Change Prochaska & DiClemente (1983) JCCP, 5, Permanent Exit Maintenance Precontemplation Action Contemplation Preparation 12

13 Stages of Change Prochaska & DiClemente (1983) JCCP, 5, Permanent Exit Maintenance Precontemplation Action Contemplation Preparation 13

14 Questions? How do I get started? 14

15 Four Processes in MI Planning Evoking Focusing Engaging Engaging Skills Micro skills Open questions Affirming the client Reflective listening Summarizing 15

16 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. 16

17 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? 17

18 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 18

19 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,

20 Questions? Recognizing and Reinforcing Change Talk and Readiness Desire Ability Reasons Commitment Behavior Change Need 20

21 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,

22 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? 22

23 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 Decisional Balance Not So Good Things about smoking Good Things about smoking 23

24 Decisional Balance Not So Good Things about smoking Good Things about smoking Alternative ways to get the Good Things 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? not at all extremely important important ICR Confident If you did decide to change, how confident are you that you could quit smoking? not at all extremely confident confident 24

25 ICR Ready How ready are you to quit smoking right now? 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 Ido to help you feel more confident? not at all extremely important /confident important /confident 25

26 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? 26

27 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? 27

28 Treatment Goals Set a quit date abrupt cessation Set a quit date reduction-to-quit Flexible quit date 1 Reduction of more than 50% is associated with increased future quit attempts 1 Hughes JR, Russ CI, Arteaga CE, & Rennard SI. Efficacy of a flexible quit date versus an a priori quit date approach to smoking cessation: a crossstudy analysis. Addict Behav Dec;36(12): Smoking reduction concerns Still need concrete goals No level of safe smoking Not proven reduce harm Compensatory smoking Withdrawal symptoms without meds Questions? 28

29 Consolidating Client Change Eliciting Commitment Is this what you want to do? Make it as public as appropriate Recognize ambivalence 29

30 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, Ph.D. marc.steinberg@rutgers.edu 30