Faculty peer reviewed
As a well-trained fourth year medical student, I inquire about smoking habits as part of almost all my patient encounters. Yet, I do not recall properly counseling a patient on smoking cessation aside from the one liner “You know you should quit, right?” During first and second year of medical school we are taught the stages of change model, which is just as obscure two years later as cell signaling pathways. I was recently introduced to what seemed like an innovative way to address smoking cessation, but it actually dates back to the last century and has been used to modify numerous risk behaviors including condom use,(1) smoking,(2) exercise,(3) and weight reduction.(4)
Motivational interviewing was first described by Miller in 1983 and defined by Rollnick and Miller in 1995 as “a directive, client-centered counseling style for helping clients explore and resolve ambivalence about behavior change.”(6) This method is founded on the patient’s readiness and confidence to change. Rollnick et al. proposed a three-phase intervention method based on motivational interviewing in 1997 that individualizes and encourages patient involvement in smoking cessation counseling.(5) This review includes a description of the three phases of motivational interviewing, using smoking cessation as the paradigm, as well as a review of evidence for and against this method.
Phase I: Quick assessment
The intervention begins with developing rapport with the patient though an open-ended question: “Can you tell me a bit about your smoking?” This initial assessment should include a disclaimer statement, such as “You may well be a little fed up with people lecturing you about smoking. I’m not going to do that, but it would help me if I could understand how you really feel about your smoking.” The physician subsequently evaluates the patient’s motivation to quit: “If, on a scale of 1 to 10, 1 is not at all motivated to give up smoking and 10 is 100% motivated to give up, what number would you give yourself at the moment?” Finally, you evaluate confidence in ability to quit: “If you were to decide to give up smoking now, how confident are you that you would succeed? If, on a scale of 1 to 10, 1 means that you are not at all confident and 10 means that you are 100% confident you could give up and remain a non-smoker, what number would you give yourself now?”
Phase II: Patient identifies problems and solutions
Following the quick assessment, the patient and physician attempt to identify problems in motivation or confidence level. Useful questions include “Why are you at (chosen number) and not at 1?” or “What would need to happen for you to get from (chosen number) to (higher number)?” or “How can I help you get from (chosen number) to (higher number)?” The physician is encouraged to offer ideas if the patient is unsure, as well as identify inconsistencies in the patient’s beliefs that create ambivalence toward smoking.
Although they are evaluated as two distinct arms, solutions to a low motivational score should be addressed prior to a low confidence score. Solutions to improve a motivational score can be identified by discussing pros and cons of smoking or providing non-judgmental information about personal risk. Conversely, if the patient is already highly motivated but lacks confidence, then phase II should include brainstorming on solutions to increase confidence, such as selecting a general problem area (e.g. tobacco withdrawal, weight gain, social situations, mood states, or stress) and encouraging the patient to individualize a practical plan. The physician can supplement with other ideas, but should not immediately offer a single, simple solution. In the end, the patient chooses the best option for him or herself.
Phase III: Target and follow up
The final phase will depend on the direction of phase II, but should reinforce the value of small gains and openness. The patient and physician should come up with a reasonable target, such as decreasing the number of cigarettes or improving other lifestyle factors that may influence smoking. Sometimes the patient may not be ready to set a target and the physician should reinforce that (s)he is available in the future whenever the patient is ready. Finally, the physician should find out how (s)he can assist in attaining the target, i.e. frequent follow-up visits, telephone calls, or nicotine replacement.
A review of the literature revealed a number of studies evaluating the efficacy of motivational interviewing. One of the first studies by Colby et al. randomized 40 adolescents in a hospital setting to either brief advice or motivational interview and found that, although there was no difference in smoking cessation at 3-month follow-up, there was a significant decrease in smoking dependence and number of days smoked in the motivational interview group.(2) More recently, Soria et al.’s randomized controlled trial of 200 smokers concluded that smoking cessation after both 6 and 12 months in the motivational interviewing group was 5.2 times higher compared to anti-smoking advice. Although motivational interviewing was first described by Rollnick et al. for smoking cessation, it has been found to be less effective for smoking cessation as a first-line method and more successful with resistant patients and increases the likelihood of future quit attempts.(8)
Since motivational interviewing has been described for a number of risk behaviors, I recently tried out the adaptability of this technique on a 68 year-old obese male. The patient had motivation to lose weight of 7/10, but confidence to succeed of 3/10. His low confidence was primarily due to the amount of weight he believed he had to lose in order to make an overall difference. Together we decided to set a reasonable goal for this month of cutting out regular Coca-Cola. Motivational interviewing individualized the patient’s care, prevented me from having preconceptions on why the patient did not try to lose weight, and was applicable to a behavior not originally described in the three phases.
Emily Stamell is a 4th year medical student at NYU School of Medicine.
Peer reviewed by Antoinette Schoenthaler, EdD.
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8. U.S. Department of Health and Human Services. Treating tobacco use and dependence: 2008 update. Atlanta, GA, U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office of Smoking and Health, 2008.