Smoking Cessation Counseling

Fayza RayesMBBCh. Msc. MRCGP

Consultant Family Physician

Joint Program of Family & Community Medicine, Jeddah

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www.fayzarayes.com

Mr. Ali, is a 45-year-old retired from military service. Presented with cough for 3 months. He has hypertension. He smokes 40 cigarettes per day. His father died of coronary heart disease when aged 48.

How you proceed?

Management of Presenting Problem

Management of Continuous

Problem

Modification of Help Seeking

Behavior

Opportunistic health Promotion

Stott & Davis 1979

Mr. Ali, is a 45-year-old retired from military service. Presented with cough for 3 months. He has hypertension. He smokes 40 cigarettes per day. His father died of coronary heart disease when aged 48.

Management of Presenting Problem

Management of Continuous

Problem

Modification of Help Seeking

Behavior

Opportunistic health

Promotion

Stott & Davis 1979

Mr. Ali, is a 45-year-old retired from military service. Presented with cough for 3 months. He has hypertension. He smokes 40 cigarettes per day. His father died of coronary heart disease when aged 48.

Health Promotion

Definition of Health Promotion

Action initiated by physician

Change in patient’s behavior

(smoking)

To increase or promote patient’s health.

Strategies of Intervention

Minimal: 1 session less than 3 min

Intermediate: 2 to 3 sessions 3 to 10 min

Intensive program: Greater than or equal

to 4 sessions greater than 10 min

Skills of Health Promotion:1. Choose appropriate time

2. Ask to find out in which stage of change

3. Proceed according to patient's reaction

4. Listen to the patient believes, worries and expectations

5. Non-judgmental Motivational Counseling

6. Make use of patient's previous experience

7. Use supportive measures

8. Put action plan

9. Use indicator to evaluate the progress

10. Follow up visit and agree on suitable target

Behavioral Counseling

Smoking diary Progressive restriction Find alternatives to oral and hand activity Avoid smoking cues e.g. coffee and cigarettes (take

orange juice instead), smoking 30 minutes after awakening (exercise)

Remove all ashtrays from the surrounding environment

Encourage partner to stop smoking Tell friends that they are going to stop Avoid situations that tempt you to smoke (parties)

First Visit: Establish rapport

Find out in which stage of change

Give objective information about smoking Non-judgmental Motivational Counseling

Discuss the pros and cons of smoking &quitting

Measure: Wt. Ht. BP. BFM (if COPD)

Do basic screening tests:

lipids & Blood sugar

Choose the

appropriate

time & show

your patient

how much

you care

Stages of Change ModelPrecontemplationNot thinking about change, uninterested

May be resignedFeeling of no controlDenial: does not believe it applies to self Believes consequences are not serious

ContemplationConsidering a changeWeighing benefits and costs of behavior X proposed change

PreparationExperimenting with small changes

ActionTaking a definitive action to change

MaintenanceMaintaining new behavior over time

RelapseExperiencing normal part of process of changeUsually feels demoralized

If pt. at Precontemplation stage discuss: Relevance: connection between tobacco use and

current symptoms, disease and medical history Risks: risks of continued tobacco use and tailor the

message to individual risk/relevance of cardiovascular disease or exacerbation of preexisting disease

Rewards: potential benefits for quitting tobacco use to their medical, financial, and psychosocial well-being

Roadblocks: barriers to quitting and discuss options and strategies to address patient's barriers

Repetition: Reassess willingness to quit at subsequent visits; repeat intervention for unmotivated patients at every visit.

Precontemplation stage

Relevance

Risks Rewards

Roadblocks

Repetition

Precontemplation stage

If pt. at Precontemplation stage discuss:

Every body has a trigger point

If pt. at Precontemplation stage discuss:

Relevance

Risks

Rewards

Roadblocks

Repetition

Precontemplation stage

Precontemplation stage

If pt. at Precontemplation stage discuss:

Relevance

Risks

Rewards

Roadblocks

Repetition

Precontemplation stage

If pt. at Precontemplation stage discuss:

Relevance

Risks

Rewards

Roadblocks

Repetition

Exercise :

Discuss possible barriers to behavior change (Roadblocks)

Barrier related to the patient: ………………………………………………………………………………… .……………………………………………………………………………….. ………………………………………………………………………………… .…………………………………………………………………………………

Barrier related to the doctor-patient relationship: .……………………………………………………………………………….. …………………………………………………………………………………. ………………………………………………………………………………… …………………………………………………………………………………

Precontemplation stage

Patient Reaction to Smoking Counseling

Why some people respond

immediately while other

people do not even think of

quitting smoking

Precontemplation stagePrecontemplation stage

Health Beliefs Model (1966)

Concept Definition

Perceived Susceptibility

Patient's opinion of how strong he is

Perceived Seriousness

Patient's opinion of how serious a condition and its squeal are

Perceived Benefits

Patient's opinion of the efficacy of the advised action to reduce risk or seriousness

Perceived Barriers

Patient's opinion of the tangible and psychological costs of the advised action

Cues to ActionPressure to activate compliance

Self-EfficacyConfidence in patient's ability to take action

Precontemplation stagePrecontemplation stage

Health Beliefs Model (1966)

How smoker may think

Advantages of smoking: Prestigious Increase concentration Decrease appetite Relaxation Fun Rebellion & Freedom …

Disadvantages: Against religion !! Cost money Affect health Children health Bad smell Not civilized

behavior …

Relation between anxiety and compliance

Compliance increase by moderate degree of anxiety But …??

Anxiety

Compliance

Health Beliefs Model

Relation between anxiety and compliance

Anxiety

Compliance

Compliance increase by moderate degree of anxiety but severe degree of anxiety decrease compliance

Health Beliefs Model

Barrier to changing Barrier to changing

BehaviorBehavior

Denial:Denial: “Not me” “I am young” “I am strong” “I walk every day” …..

Second Visit (within 10 days):

Maintain effective dr-pt relationship Discuss action plan if the patient is

ready Make use of pt's previous experience Discuss withdrawal symptoms &

management Use supportive measures

Family support Nicotine supplement Cognitive treatment

Use Supportive Measures:

Third Visit (within 1-2 Weeks):

Maintain effective dr-pt relationship

Follow up withdrawal symptoms

Use indicator to evaluate the progress

Agree on suitable target

Be flexible, empathic & give hope

Empathic & Respond to Patient Cues

Is this an appropriate time ?!

Till me about your smoking?

Quitting smoking is a hard task…

Appreciate Difficulties

Give the patient hopehope

Forth Visit (On demand):

Maintain effective doctor-patient relationship

Diagnose possible relapse early and manage

If patient relapsed … start all over again

Be patient,

nonjudgmental

& have hope

Common Mistakes in Counseling

Some patients are hopeless and no need to counsel them

Trying to convince the patient to change behavior irrespective to his readiness to change

Threat the patients instead of instill hope

No enough follow up

Message to take home

1. Opportunistic health promotion is

a basic task in any consultation

2. Be supportive, empathic, patient, nonjudgmental and have hope

Thank you