Motivational interviewing for tobacco use cessation can be a powerful tool to reach people who aren’t ready to quit.
As tobacco treatment specialists, we often have to talk to people about their tobacco use who are not ready to quit. These conversations can be challenging, especially if the person was sent to you because he or she needs to quit prior to surgery or after a new cancer diagnosis.
I recently had a clinic patient start our first meeting saying, “I’ll tell you right now, I’m not going to quit smoking.” Maybe you’ve had a similar experience and thought, as I did, “Where do I go from there?”
To answer this question, I sat down with Susan Trout, Associate Director for the Outpatient Tobacco Treatment Clinic at the UNC Family Medicine Center. A Licensed Clinical Social Worker with a Master of Science in Public Health, one of her areas of expertise is Motivational Interviewing (MI). MI is an evidence-based counseling approach for eliciting behavior change that is patient centered. It can be especially helpful when someone is not ready or ambivalent about making a change.
“I really appreciate the opportunity to help people make positive changes in their life,” Susan says of her work as a tobacco treatment specialist. “Behavior change isn’t easy; using Motivational Interviewing can help clients discover their own strengths and motivations for change.”
"In counseling we don’t always get the opportunity to know if we’ve been successful; sometimes we are just planting seeds to grow later. Motivational Interviewing can help you navigate difficult conversations that hopefully will lead to change."
One problem she encounters often is a culture issue around how tobacco use is viewed. “Tobacco treatment lots of times doesn’t get the same spotlight as other addictions, and it doesn’t allow people to recognize how hard it is to quit. People feel like they should just be able to quit, and when they can’t, it is discouraging.”
How do you approach people who don’t want to quit?
It really depends on the area you are working in. You have to tailor your message to your setting.
Inpatient: A good place to start is helping patients be comfortable while in the hospital by treating nicotine withdrawal. This usually leads to a discussion of using medications. Then, from that point, you can find out about previous cessation medication use and what the person's interest is in quitting.
Outpatient: Tailor your message to their current health issues related to tobacco use or their health goals. For example, when working with a patient on diabetes or cardiac care, discuss the things they can do to improve their health—exercise, change of diet, and tobacco use—blend it in. Then ask, “What are your thoughts?”
Patients Having Surgery: Suggest using a lot of reflective listening in the beginning to help the person to know that you hear them. Try not to jump too far ahead. Patients sometimes need to quit as a requirement of surgery, not necessarily because they want to quit. If that is the case, saying something like, “Let’s be tobacco free for the surgery. Let’s not think about forever, just right now.” Sit with them in their feelings of frustration or anger. If you get an eye roll, acknowledge by saying something like, “Tell me what you are feeling right now.”
Patients with Cancer or Chronic Lung Disease: Look for an opportunity to provide education around the positive benefits of quitting their tobacco use. For example, “Good things start to happen within the first hour of quitting.” For incurable disease, maybe the focus is wanting to feel better or having control over something. Look for ways you can help them see a different perspective. “Are there things that would be really good about quitting after a cancer diagnosis?” One patient shared, “I want my kids to know that I’m doing everything possible for my cancer.” Find out their why.
Adolescents: Sometimes they want to quit because they feel like they are addicted. For others, it may be ways the tobacco is impacting their lives:: “I’ve already gotten in trouble at school,” or “I cannot play on my sports team.” Focus on consequences in the moment. Those often become the motivation. It is also important to provide education on the risks of using a vape or other tobacco products. Acknowledge the impact of their peers: “It’s really hard when it feels like all of your friends are doing it.”
How do you use Motivational Interviewing in a tobacco treatment visit?
Rapport building is essential and an important place to start. Sometimes it is okay to have a really brief conversation and then leave the door open for the person to come back to it, depending on how resistant the person is. Sometimes you need to table the idea of quitting so you don’t ruin the rapport you’ve built.
Listening to patients is another important step. Understand their wants. This is how you get buy in. Find common ground you both have. Acknowledge where the person is and that you hear that. Are they really stressed, or is there some other barrier to quitting? Can they verbalize at least one thing that can be good about working on their tobacco use? This is Change Talk; you want to listen for it and support it.
Allow the person autonomy. They need to feel that this is their choice. Are there things that help them feel more interested or confident in working on their tobacco use? It is important to not force people into a treatment plan. We want people to feel they are making this change for themselves, not that it got pushed on them.
What are your top 3 takeaways for success with Motivational Interviewing?
Learn about reflective listening. Listen and then acknowledge what the person is feeling. This is great for de-escalation. Practice this technique.
Avoid the Righting Reflex. When patients present a problem, don’t solve it for them. Ask permission to provide education. Support their autonomy. It doesn’t mean we necessarily agree with what they are saying. This leaves the door open to future change.
Make goals based on the person’s stage of change. Not everyone may have a goal of quitting. If someone is contemplating change, explore their reasons for and barriers to change. Cutting down on tobacco use or making one tobacco use behavior change (i.e., “I will keep my cigarettes in another room.”) can be a more attainable place to start.
To learn more about Motivational Interviewing and other behavioral techniques for addressing tobacco use, join our upcoming half-day, virtual CE course—Intensive Behavioral Approaches to Tobacco Treatment—on May 21, 2024. Visit https://www.dukeunctts.com/shortcourses to learn more or register.
About the Author
Rachael Joyner, DNP, FNP-BC, APRN, is a family nurse practitioner with the Duke Smoking Cessation Program. She holds a National Certificate in Tobacco Treatment Practice and received her Doctorate in Nursing Practice from the University of Florida. She loves working collaboratively with patients to help them become tobacco free.