Unwillingness to Quit Tobacco: The 5 Rs

Encourage patients to indicate why quitting is personally important to them. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation).

Use open ended questions to explore patient perceptions about quitting:

• "How important do you think it is for you to quit smoking?"
• "What might happen if you quit?"

Use reflective listening to seek shared understanding:

• "So you think smoking helps you to maintain your weight."
• "What I have heard so far is that you enjoy smoking. On the other hand, your boyfriend hates your smoking and you're worried you might develop a serious disease."

Normalize feelings and concerns:

• "Many people worry about managing without cigarettes."

Support the patient's autonomy and right to choose or reject change:

• "I hear you saying you're not ready to quit right now. I'm here to help when you are ready."
   

Ask the patient to identify any potential negative consequences of tobacco use. Emphasize that using low-tar/low-nicotine cigarettes or other forms of tobacco (e.g., smokeless tobacco, cigars and pipes) will not eliminate these risks.

Examples of risks are:

• Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility and increased serum carbon monoxide.
• Long-term risks: Heart attacks and strokes, 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, Sudden Infant Death Syndrome, asthma, middle ear disease and respiratory infections in children of smokers.

Highlight discrepancies between the patient's present behavior and expressed priorities, values and goals:

• "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."
• "We would like to help you avoid a stroke like the one your father had."
   

Encourage the patient to identify potential benefits of stopping tobacco use. Highlight the benefits that seem most relevant to the patient.

Examples of benefits include:

• Improved health
• Better-tasting food
• Improved sense of smell
• Saving money
• Feeling better about yourself
• Better-smelling home, car, clothing, breath
• Putting an end to the distraction of worrying about quitting
• Setting a good example for children and grandchildren
• Having healthier babies and children
• Not having to worry about exposing others to smoke
• Feeling better physically
• Performing better in physical activities
• Reducing wrinkling/aging of skin
• Improving oral health and less yellowing of teeth

Help the patient to identify and build on past successes

• “So you were fairly successful the last time you tried to quit.”

Offer options for achievable small steps toward change:

• Contact QuitlineNC (1-800-QUIT-NOW) for advice and information.
• “Work on changing your tobacco use” (e.g., no tobacco use in the home).
• “What ideas do you have for trying to quit?”
   

Ask the patient to identify barriers to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address those barriers. Typical barriers might include:

• Withdrawal symptom
• Fear of failure
• Weight gain
• Lack of support
• Depression
• Enjoyment of tobacco

Back off and use reflection when the patient expresses resistance:

• “Sounds like you are feeling pressured about your tobacco use.”

Express empathy:

• “You are worried about how you would manage withdrawal symptoms.”

Ask permission to provide information:

• “Would you like to hear about some strategies that can help when you quit?”
   

The motivational intervention should be repeated every time an unmotivated patient visits the practice.