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Patient Stages of Change

Now we will discuss in more detail your role in helping your patients stop smoking.  This technique works with behavioral components of any disease.  As you become more comfortable with the technique, you will find yourself using it more and more frequently.

Here is the easy way to stage the patient.  Six months is chosen because it is considered to be the “foreseeable future.”

Studies performed in the US show that, although most smokers (about 70%) want to stop smoking at some time, only a minority (about 15%) are ready to stop smoking at any given time.

Prochaska and DiClemente developed a model of the structure of people’s efforts to change their own addictive behavior [DiClemente and Prochaska’s Transtheoretical Model of Change (Processes and Stages of Change), www.uti.edu/research/crpc, 1985)].  The basic constructs of their ‘stages of change’ theory are:

• Most people change through a cyclical process, with relapse being a normal part of the process.
• Tobacco control policies and interventions can more effectively influence people not to smoke, by segmenting the public according to stages in the tobacco control addiction cycle. Tobacco companies know this, and base their marketing decisions in a given market on the prevalence of consumers at the different stages in that market.
• Relapse prevention is an ongoing process in which patients who have quit smoking try to anticipate circumstances or cues that would likely prompt them to resume smoking.  Triggers may be physical or psychological, including stress, social influences, withdrawal symptoms, weight gain, and depressed mood.  Relapse prevention involves practicing avoidance of these triggers.  A patient must devise coping strategies (have a plan of action to deal with triggers).

This takes about 10 seconds of your time. It sets the stage so that your patient knows what to expect and is more effective than the usual 10 minute lecture about the pathophysiology of lung cancer.  One can have a stop smoking handout available to give to the patient as well.

Doctor-patient dialogue is essential for quitting smoking.  In addition to asking and advising, physicians need to provide the effective tobacco treatments covered by a patient’s health plan to comply with tobacco cessation treatment guidelines by the U.S. Public Health Service.

Ask patients about tobacco use.
Advise smokers to quit.
Assess smokers’ willingness to try quitting.
Assist smokers with cessation treatment and referrals.
Arrange for follow-up contacts.

Few smokers ask for help—we need to be proactive and not wait for patients to ask.

Motivational interviewing, person-centered, and brief intervention techniques allow for the patient to “discover” their own internal motivating factors. Thus, clinicians can/should allow the patient to identify their own personal reasons for becoming a “nonsmoker.”

Clinicians should realize that during the contemplation stage, ambivalence is a normal state of being, and, as such, we can help our patients to identify the pros and cons of smoking and the pros and cons of quitting. Through this introspection, patients can begin to manage the hurdles rather than dismissing it out of hand.

Setting a quit date can be an important part of the cessation process.  Guidelines for helping patients set a quit date include:

1. The patient should choose a date that is personally meaningful – a day to look back on and remember;
2. Patient should allow plenty of time to properly prepare for the quit/start date.  Setting the date too early may lead to inadequate preparation time (e.g. medication selection and adherence, behavior change, etc.). Likewise, setting the date too late may lead to anticlimactic emotions;
3. Once a patient commits to a date, assist the patient in preparing for that date.

As you go along in this, you will hear stories from patients which will help you with other patients (for those of you who don’t have stories of your own!).

Consider your patients with diabetes:  Every glucose > 200 mg/dl is a “slip” and every glucose > 300 is a “relapse”.

Consider your patients with hypertension:  Every systolic BP >140 is a “slip” and every systolic BP > 180 is a “relapse”.

Why are we less judgmental with diabetes and hypertension than we are with addiction?

We don’t recommend announcing to patients that we expect them to relapse; however, we want them to feel free to tell us, so that we can help them re-achieve abstinence. 

Challenges, or barriers, to quitting smoking must be addressed.  Recognition of and work on breaking down these barriers before and after one quits smoking can help control nicotine addition.

Fear of failure - Don’t get weighed down by past attempts.  An unsuccessful attempt can be learning process.  We all improve with practice.

Fear of gaining weight -- Weight gain is not automatic.  Some people gain a bit; others actually lose.  Exercise and careful snacking can help reduce weight gain.

Perceived loss of identity -- Lighting up a cigarette has become second nature.  Changing is hard.  Remembering the benefits of being a non-smoker will help address this barrier.

Increased nervousness – One may use cigarettes as a coping mechanism.  Be prepared to control smoking triggers – learn healthy ways to cope.

Use positive encouragement.  A slip can be useful in terms of knowing what worked, what did not work, and what to do differently.

Web Sites

• Treatobacco.net  http://www.treatobacco.net/English/home/home.cfm.html   
• Cancer Control PLANET http://cancercontrolplanet.cancer.gov/  
• The Health Consequences of Smoking: A Report of the Surgeon General http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm
• NIDA InfoFacts: Cigarettes and Other Nicotine Products  http://www.nida.nih.gov/Infofacts/Tobacco.html
• Treating Tobacco Use and Dependence: Clinician's Packet http://www.ahrq.gov/clinic/tobacco/
• You Can Quit Smoking  http://www.surgeongeneral.gov/tobacco/consquits.htm
• Reducing Tobacco Use: A Report of the Surgeon General  http://www.surgeongeneral.gov/library/tobacco_use/
• Women and Smoking: A Report of the Surgeon General  http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2001/index.htm 
• Guide to Community Preventive Services http://www.thecommunityguide.org/tobacco/

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Last Published: 6/23/2008