The "5 R's"
For patients not ready to make a quit attempt at this time, clinicians should use a brief intervention designed to increase motivation to quit.
Patients unwilling to make a quit attempt during a visit may lack information about the harmful effects of tobacco, financial resources, may have fears or concerns about quitting, or may be demoralized because of previous relapse. Such patients may respond to a motivational intervention to educate, reassure, and motivate, such as the "5 R's": relevance, risks, rewards, roadblocks, and repetition.
Motivational interventions are most likely to be successful when the clinician is:
- empathic
- promotes patient autonomy (e.g., choice among options)
- avoids arguments
- and supports the patient's self-efficacy (e.g., by identifying previous successes in behavior change efforts)
Relevance
Encourage the patient to discuss why quitting is personally relevant, being as specific as possible. 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).
Risks
The clinician should ask the patient to identify potential negative consequences of tobacco use. You may suggest and highlight those that seem most relevant to the patient and emphasize that smoking low-tar/low-nicotine cigarettes or use of 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, 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 by children of tobacco users; increased risk for low birth weight, SIDS, asthma, middle ear disease, and respiratory infections in children of smokers.
Rewards
The clinician should ask the patient to identify potential benefits of stopping tobacco use. You may suggest and highlight those that seem most relevant to the patient.
Examples of rewards follow:
- Improved health.
- Food will taste better.
- Improved sense of smell.
- Save money.
- Feel better about yourself.
- Home, car, clothing, breath will smell better.
- Can stop worrying about quitting.
- Set a good example for children.
- Have healthier babies and children.
- Not worry about exposing others to smoke.
- Feel better physically.
- Perform better in physical activities.
- Reduced wrinkling/aging of skin.
Roadblocks
The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problem solving, pharmacotherapy) that could address barriers.
Typical barriers might include:
- Withdrawal symptoms.
- Fear of failure.
- Weight gain.
- Lack of support.
- Depression.
- Enjoyment of tobacco.
Repetition
The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.
*Fiore MC, Jaén 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 2008.