Disease=a=Month” Volume 48 Number 7 July 2002

Understanding People Who Smoke and How They Change: A Foundation for

Smoking Cessation in Primary Care, Part 2

David Goldberg, MD

Senior Physician and Codirector, Smoking Cessation Clinic Division of General Medicine

Cook County Hospital Assistant Professor of Medicine

Rush University Chicago, Illinois

Arthur Hoffman, MD, MPH

Director, Section of Preventive Medicine, and Codirector, Smoking Cessation Clinic Division of General Medicine

Cook County Hospital Assistant Professor of Preventive Medicine

Rush University Chicago, Illinois

Donna Aiiel, MD

General Internal Medicine Fellow Division of General Medicine

Cook County Hospital Chicago, Illinois

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Disease=a=Month’” Understanding People Who Smoke

and How They Change: A Foundation for Smoking Cessation in Primary

Care, Part 2

Foreword

Abstract

An Overview of Recommendations for Physician-delivered Smoking Cessation: The Public Health Service Clinical Practice Guideline

Evaluating and Coaching People Who Smoke Evaluating People Who Smoke Stage-sensitive Strategies for Coaching People Who Smoke

Visualization of the Unpleasant Aspects of a Cigarette

Clinical Vignettes Zena Luther

Epilogue

Acknowledgment References

444 445 446

451 452 459 466 474 475 475 482 483 483

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DM, July 2002 443

Foreword Dr David Goldberg and his colleagues, Dr Hoffman and Dr Afiel, provide

us with a delightful article on how to help our patients quit smoking. The authors provide us with practical information on the theory of smoking cessation using behavior modification and several clinical vignettes that allow the physician to walk the steps down the road of cessation with his or her patients. Dr Goldberg references the behavior modification techniques known as the transtheoretical model of change. While reading these methods of behavior change, I felt a ring of familiarity with the information provided, a certain, “so that’s why it worked,” when I recalled clinical experiences that were familiar from social dynamics but not from theory. Often we busy ourselves with the correctness of our medical reasoning and clinical advice without remembering that the patient must be not only willing, but behav- iorally ready, to accept our advice. This article provides the latest help on smoking cessation and practical advice on behavior changes in all types of clinical practices.

This article will be delivered in 2 issues. In part 1, the authors review the statistics on smoking and smoking cessation, the theories of nicotine dependence, and the stress-reaction cycle and its impact on health. The authors then lead us through a practical description of the science of behavior change and how this may be used in clinical practice to help individuals break habits.

In part 2, Dr Goldberg and his colleagues introduce the reader to smoking cessation, reviewing the Public Health Service clinical guidelines for smok- ing cessation. The authors discuss the fact that the transtheoretical model of change is an underlying theory in these public clinical guidelines. Evaluating and coaching patients who smoke completes the theory on how to understand the level of readiness and ability to change behavior in your patients. In each part, the authors review through clinical vignettes the situations of 4 individuals who have tried to quit smoking. These patients are reviewed further to develop an understanding of the readiness and ability to quit smoking. Drs Goldberg, Hoffman, and ACel should be applauded for their clear descriptions and practical advice on smoking cessation, advice you can incorporate from theory to bedside on the use of behavioral change to impact a serious and pervasive public health problem.

Janis M. Orlowski, MD Editor-in-Chief

444 DM, July 2002

Understanding People Who Smoke and How They Change: A Foundation

for Smoking Cessation in Primary Care, Part 2

David Goldberg, MD, Arthur Hoffman, MD, MPH, Donna Afiel, MD

The purpose of this 2-part article is to develop an understanding of people who smoke and how they change as a foundation for the delivery of smoking cessation interventions in primary care. Central to our approach is the transtheoretical model of change (TMC). The TMC is an evidence-based model of behavior change that has been developed and tested during the past 2 decades by Prochaska and his colleagues in the context of smoking cessation. We use a review of the literature, in-depth interviews of people who successfully quit smoking, and our experience applying the TMC in the context of primary care and a smoking cessation clinic to explore the clinical work of smoking cessation.

This is part 2 of the article “Understanding People Who Smoke and How They Change: A Foundation for Smoking Cessation in Primary Care.” Part 1 describes the theoretical information known about smoking ces- sation: why smoking is a powerful behavior, the scien- tific background of the TMC, and the building-block constructs of the TMC. The first section of part 2 is a review of the Public Health Service clinical practice guideline, Treating Tobacco Use and Dependence, pub- lished in 2000. The second chapter of part 2 is a

Dis Mon 2002;48:44.5-85 001 l-5029/2002 $35.00 + 0 62/l/129141 doi:l0.1067/mda.2002.129141

DM, July 2002 445

discussion of clinical assessments and strategies for working with smokers grounded in the Public Health Service practice guideline, our understanding of people who smoke, and the TMC. Woven throughout are transcripts of interviews with 4 people in which they describe their experiences smoking and their pathways to cessation.

An Overview of Recommendations for Physician- delivered Smoking Cessation: The Public Health Service Clinical Practice Guideline For the primary care physician, the literature in smoking cessation can be daunting. A computer-generated search with the key word “smoking cessation” yields more than 2000 English-language citations since the middle of 1998. The literature is so vast that any one practicing provider is likely to be familiar with only limited aspects of the literature. In response to the burgeoning research in the field, the literature relevant to physician-delivered smoking cessation has been methodically distilled in a consensus statement developed under the auspices of the Public Health Service, and published in 2000.9,10 The consensus statement includes both a review of the literature, with a series of meta-analyses assessing treatment modalities and intensities, and a set of recommendations for physician-delivered smoking cessation, smoking cessation specialists, and institutional changes in health care to promote smoking cessation. We will summarize the recommendations of the consensus statement for physician-delivered smoking cessation. The full report is available online at http://www.surgeongeneral.gov/tobacco/treating_tobacco_use.pdf.

The core of the recommendations for physician-delivered smoking cessation is a 5-step approach: (1) ask about tobacco use; (2) advise to quit; (3) assess willingness to make a quit attempt; (4) assist in quit attempt; and (5) arrange for follow-up. Each of these steps is described in more detail below.

Ask About Tobacco Use The panel recommends that an inquiry be made as to the smoking status

of every patient at every visit. The odds ratio (and 95% confidence interval) for systematic identification of smoking status on the presence of an intervention during the clinical visit is 3.1 (2.2-4.2) and on cessation is 2.0 (0.8-4.8). The panel recommends that smoking status be included as a vital sign, with chart stickers or a computerized registry with prompts as alternatives.

446 DM, July 2002

TABLE 1. Characteristics of interventions to enhance motivation to quit’,”

Relevance Encourage the patient to indicate specific personally relevant reasons to quit.

Risks

Rewards

Roadblocks

Repetition

Offer information that is relevant to the patient’s health status, history of quit attempts, and social and family circumstances.

Offer additional information to members of special populations (pregnant women, adolescents, and racial and ethnic minorities).

Ask the patient to identify potential negative consequences of smoking. Highlight relevant risks and suggest additional relevant risks. Risks include acute risks, long-term risks, and environmental risks to

others. Ask the patient to identify potential rewards of cessation Suggest and highlight the most relevant rewards. Rewards include health, well-being, hygiene, more discretionary income,

and pride in accomplishment. Ask the patient to identify barriers to quitting. Inform the patient that specific interventions can help overcome barriers. The roadblocks include withdrawal, low self-esteem, depression, weight

gain, and pleasure. Efforts to motivate the unmotivated should be repeated at each visit. Individuals who failed an attempt should be assured that most need

repeated attempts.

Advise to Quif The report emphasizes that the advice should be clear (with regard to

quitting as opposed to cutting down), strong (in reference to the staggering burden of disease from smoking), and personalized (to the health, readiness to quit, and life circumstances of the individual patient).

Assess Willingness to Make a Quit Attempt Patients should be triaged into 3 categories: those willing to make a quit

attempt who need or want limited assistance; those willing to make a quit attempt who are willing to attend or need intensive assistance; and those unwilling to quit. Those unwilling to quit should receive a motivational intervention. The guideline notes that this motivational intervention is most likely to be successful when clinicians maintain empathy, promote patient autonomy, avoid arguments, and support patient self-efficacy.* The character of the motivational intervention is shown in Table 1.

*The principles for motlvatlng smokers who are noi ready to quit smoiong used by ihe Public Health Service guideline come from the field known as motivational interviewing.’ “12 Specialists in the treatment of alcoholism and addictions developed motivational interviewing. The transtheoreiical model of change that we describe in this article influenced the development of motivational interviewing. ” Motivational interviewing has been tested in only limited studies of physician- delivered smoking cessation. 13’14 We do not review motivational inteivlewing in this article.

DM, July 2002 447

Assist in Quit Attempt The panel enumerates 6 components of assisting a quit attempt. They

are:

0 Help with a quit plan. Help the patient set a quit date within 2 weeks. Ask the patient to inform family, friends, and coworkers about the intention to quit. Anticipate challenges to quitting, including possible nicotine withdrawal symptoms. Get rid of cigarettes and smoking paraphernalia. In the days preceding the quit date, consider changing the pattern of smoking so that the patient avoids smoking in places that usually trigger the desire for a cigarette.

0 Provide practical counseling for problem solving and skills training. Clarify the goal of complete abstinence. Review past experiences with quitting. Identify triggers and difficult situations and consider strategies for coping with them.

0 Provide intratreatment social support. Inform the patient that the physician and medical staff are available for ongoing support.

0 Help identify extratreatment social support. Suggest and help the patient identify a family member or friend who will be available to support the quit attempt.

l Recommend the use of approved pharmacotherapy, except in special circumstances. The guideline recommends 1 of 5 first-line medications (nicotine gum, nicotine patches, nicotine nasal spray, nicotine inhaler, or bupropion sustained release). Second-line med- ications for those unable to use one of the first-line medications are clonidine and nortriptyline. Patients should be informed that these medications increase successful cessation and decrease withdrawal symptoms. The patients for whom medications are not recom- mended are those with contraindications and light smokers (fewer than 10 cigarettes a day). A brief summary of first-line medications is found in Table 2.

l Provide supplementary materials. There are a variety of self-help materials produced by government and nonprofit agencies that can be offered to patients. The guideline offers the Web site addresses of agencies producing selected materials.

Arrange for Follow-Up The follow-up can be in person or over the telephone. Follow-up should

be timed to occur during the first week of the quit attempt and again within the first month. The follow-up is a time to congratulate successes, recommit to abstinence, problem solve with respect to tempting situa-

448 DM, July 2002

tions, and assess use of medications. Referrals to smoking cessation specialists may be reconsidered if patients are encountering particular difficulties.

Relapse h-even tion In addition to helping patients initiate a quit, the guideline recommends

relapse prevention, especially during the first 3 months of a quit attempt. Relapse prevention should include discussion of benefits of cessation, successes, and problems encountered or threats to continued abstinence. Common problems that may be identified and specifically addressed include lack of social support, negative mood states or depression, strong or prolonged withdrawal symptoms, weight gain, and waning motivation or belief of being deprived.

The Guideline We encourage physicians to read the guideline. The guideline represents

a comprehensive synthesis of an enormous body of information focusing on physician-delivered smoking cessation by a group of people distin- guished by the breadth of their skill and commitment to the field of smoking cessation. Chapter 3 of the report has the recommendations of the consensus panel for physician-delivered smoking cessation. Chapter 6 reviews the meta-analyses completed as part of the formulation of the recommendations. Chapter 6 also includes more detailed information on instructions for medication usage. Chapter 7 reviews the data regarding special populations and Chapter 8 reviews the data on topics such as weight gain and noncigarette tobacco products.

The methods of the consensus process rest on review of randomized, controlled trials of physician interventions and placebo-controlled medi- cation trials. The very sharp focus of their work is on what has been demonstrated to work, on the basis of rigorous methodology, in the context of physician-delivered smoking cessation. The work that we are exploring in these 2 issues of Disease-a-Month is the research of James Prochaska, PhD, and his research team. The focus of their work has been how people change their smoking behavior, with application of the principles of change to self-help. Because much of their research involves descriptive methodologies and their trial interventions involve tests in the context of self-help, their research was not specifically reviewed and incorporated into the guideline. This was a reasonable decision for the consensus panel. However, it does not preclude there being lessons for physicians from this complementary, rigorously developed body of work.

Lessons from transtheoretical model of change (TMC) are making their

DM, July 2002 449

TABLE 2. Summary of smoking cessation pharmacotherapy: First-line medications’,”

Drug Dosing Side effects and contraindications

Nicotine gum

(OTC)

Nicotine patch (Nicoderm CQ and Nicotrol OTC, generic patches by prescription)

One spray to each nostril (1 mg total

Nicotine nasal spray (prescription) nicotine) Initial dose

is 1-2 doses per hour, as needed, for symptom relief. Minimum treatment is 8 doses/day. The maximum is 40 doses/day and 5 doses/hour. Each bottle contains 100 mg of nicotine.

2-mg and 4-mg pieces to be used on a schedule or as- needed. The 4 mg gum is recommended for people who smoke ~25 cigarettes/day. Up to 24 pieces of gum may be used daily. Scheduled use (q 1-2 hours) for 1 to 3 months may be better than as- needed use.

One patch every day. Nicoderm CQ is a 24.hour patch that comes in 3 doses for tapering. The recommended dosing scheme is 21 mg for 4 weeks, 14 mg for 2 weeks, and 7 mg for 2 weeks. Nicotrol is a 16.hour patch that comes in 15 mg for 8 weeks.

Side effects: Mouth or jaw soreness, dyspepsia (due to swallowed nicotine). Contraindications: None, although use might be difficult for people who have poor teeth or dentures. Caution: Unstable angina, 2 weeks after myocardial infarction, serious arrhythmia.

Side effects: Local skin reactions in up to 50%; 5% require discontinuation. Rotating sites reduces intensity of reactions. Low-dose steroid cream may be used to treat. Insomnia. Caution: Unstable angina, 2 weeks after myocardial infarction, serious arrhythmia.

Side effects: Moderate to severe nasal irritation (91% on first 2 days) that declines in severity with continued use. Dependence potential is intermediate between cigarettes and other nicotine replacement products. Contraindications: Severe reactive airway disease. Caution: Unstable angina, 2 weeks after myocardial infarction, serious arrhvthmia.

Instructions

Chew the gum slowly until a taste of mint or pepper occurs. Then park the gum between the cheek and gum to permit absorption through the oral mucosa. Repeat and continue for approximately 30 minutes. Avoid acidic beverages (coffee, juice, soft drinks) or eating for 15 minutes before and during use.

At the start of each day, place a fresh patch on a relatively hairless area of skin between the waist and neck. If sleep disruption occurs, the patch may be worn only during waking hours.

Avoid sniffing, inhaling, or swallowing during administration as irritating effects are increased. Tilt the head back slightly during administration.

450 DM, July 2002

TABLE 2. Continued

Drug Dosing Side effects and

contraindications Instructions

Nicotine One puff as needed. A inhaler cartridge delivers 4 (prescription) mg of nicotine in .the

course of 80 inhalations. 6-16 cartridges should be used per day, with tapering of use in the last 6-12 weeks of therapy.

Bupropion 150 mg BID, sustained beginning qAM X 3 release days (prescription)

Side effects: Local irritation of mouth and throat (40%), cough (32%), and rhinitis (23%). Contraindications: None.

Temperatures below 40°F decrease nicotine delivery. Avoid acidic beverages or eating for 15 minutes before use. Duration of therapy is for up to 6 months.

Side effects: Insomnia (35% to 40%) and dry mouth (10%). Contraindication: Seizure disorders, eating disorders, use of MAO inhibitor in past 2 weeks.

Begin bupropion 1-2 weeks before the quit date. The duration of therapy is 7-12 weeks and may be extended up to 6 months.

way into discussions of medical care with respect to behavior change. The TMC is slowly being referenced in the primary care and internal medicine literature and board review materials. However, the TMC has not been comprehensively reviewed in journals commonly read by primary care or internal medicine specialty care physicians. We believe that understand- ing how people change can lead to insights that will help physicians apply the coaching aspects of the consensus panel recommendations with insight and self-confidence.

Physicians have yet to fully embrace the recommendations developed by the consensus process. Whereas a majority of physicians report asking about smoking and advising cessation, few assist their patients or arrange follow-up. l5 Along with disseminating the guideline recommendations, finding ways to enhance physician skills may be one way to build the commitment of physicians to the cessation activities highlighted in the guideline. In this context, we have written this article.

Evaluating and Coaching People Who Smoke In this section, we will offer ideas for evaluating and coaching people who smoke. We have selected the term “professional coaching” to describe the physician role. We like the term “coach” because it is clear that coaches don’t play the game. They can help players prepare and they

DM, July 2002 451

can give pointers, but coaches sit on the sidelines. A good coach is a patient observer, with a keen eye for small changes and a vision of what is possible. Whereas in sports many coaches are paternal, authoritarian figures, we are not suggesting this style of coaching. We use the term “professional coach” to imply a teaching, facilitative, and promoting role, consistent with patient-centered work.

Behavioral change is a central component of successful preventive intervention in primary care. We, the authors, were not taught a model for understanding behavioral change in medical school or internal medicine training spanning the last 30 years. The ideas in this chapter have been developed during our collective, personal 30 years of experience guiding smokers toward cessation, 16 years of experience teaching stress reduc- tion, and our understanding of the literature. The ideas we offer are strongly influenced by the holistic and systematic conception of behav- ioral change offered by the TMC.

Our approach is influenced by the TMC, even though the model has not been tested in primary care in a rigorous, long-term trial. In one sense, then, we are stepping beyond the base of the evidence. We are stepping out on this limb with humility. We do so willingly because applications of the principals of the TMC have made it easier for us to make deep connections, in brief periods of time, to our patients who smoke. The impact (the participation rate multiplied by the cessation rate) of the TMC in self-help programs for smoking is inspirational to us in our efforts to deliver preventive interventions in primary care.*

We hope the TMC will help you understand and apply the guidelines for cessation described previously and hone your skills in the promotion of cessation of smoking. In addition, we hope that any understanding that you gain from this article leads to greater connection for you with your patients who smoke. In the absence of evidence for or against this approach leading to cessation, we believe human interconnectedness remains a guiding force for the work of physicians.

Evaluating People Who Smoke Evaluation of people who smoke is not done only once. As demon-

strated in the clinical vignettes in this and the previous issue (Dis Mon 2002;48:385-439), each individual has a style and pace of change, with an unfolding of the stages. Because stages are shifting, so, too, are smokers’ decisional balance, self-efficacy/temptation, and use of processes. Eval- uation of the development of these constructs during sequential visits creates the groundwork for a common-sense, tailored, evolving approach to coaching. As we will describe below, the evaluation is also an

452 DM, July 2002

TABLE 3. An algorithm for assessing stage of readiness for smoking cessation

Are you currently a smoker? Yes, I currently smoke No, I quit within the last 6 months (action stage) No, I quit more than 6 months ago (maintenance stage) No, I have never smoked (nonsmoker)

For smokers only: In the last year, how many times have you quit smoking for at least 24 hours? Are you seriously thinking of quitting smoking?

Yes, within the next 30 days (preparation stage if they have one 24hour quit attempt in the past year [refer to previous question; contemplation stage if there has been no quit attempt]

Yes, within the next 6 months (contemplation stage) No, not thinking of quitting (pre-contemplation stage)

Reprinted with permission from J Consult Clin PsychoIl and Cancer Prevention Research Center.l’ Available online at the Web site: http://www.uri.edu/research/cprc/Measures/Smokingll.htm.

intervention. In our work, evaluation and coaching are both ongoing over time.

Determining a Smoker’s Readiness to Change. Clinically, it might seem elementary to elicit answers to the staging algorithm questions (Table 3).16-18 But, our experience in training physicians through role- plays” and clinical observations suggests that using the exact language of these questions in a nonjudgmental style is not simple.

It is easy to replace “Are you seriously thinking about quitting?” with “Do you want to quit?” Comparing the questions “Do you want to develop your counseling skills?” and “Are you seriously thinking about developing your counseling skills?” gives you an idea how different these questions are. It is easy to leave out the word “seriously,” again shifting the meaning. It is easy to use a tone of voice or body language that communicates impatience or frustration with continued smoking when asking the staging questions. It is probably best to choose your time to ask these questions when you feel patient, and can take time to listen to yourself ask them. If it is more suitable for your setting, the staging algorithm can be delivered as a waiting room health evaluation for all new patients and as part of follow-up of those who smoke.

Even with care given on the provider’s part, the smoker may be threatened by the content of the questions. Some may become defensive or anxious no matter how unthreatening and nonjudgmental your presen- tation. From our point of view, this gives you more information. It is likely that the smoker whose body language or words are defensive is a precontemplator, not someone who is a committed smoker, because

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TABLE 4. How to use the staging algorithm

Practice using the algorithm questions exactly. Ask the questions when you feel patient; avoid asking them when you feel rushed. Listen to your tone as you ask the questions. Be prepared to let the pre-contemplator be defensive and the contemplator be anxious. Focus on gathering useful information for your intervention. Consider using a written form to be completed in your waiting room at each visit.

persons who really want to keep smoking are able to discuss their views calmly. It is likely that the smoker whose body language or words express anxiety is a contemplator.

Seen this way, an emotional response by the smoker while you are eliciting information about readiness to change becomes an observation useful for diagnosis and for formulation of treatment plans. An emotional response is a measure of the internal environment of the smoker. Seen in this way, responses that are often awkward and difficult in the clinical encounter can be understood as observations or data points, rather than a basis for reaction. Just as the blood sugar is important in the diagnostic plan of a diabetic, the internal environment of the smoker is easy to observe and is an important part of the diagnostic plan for the smoker. Table 4 summarizes the application of the staging algorithm.

Determining Reasons to Smoke and Reasons to Quit. The decisional balance scale20,21 reveals to both provider and smoker which specific reason or reasons to smoke (stress reduction, concentration, or pleasure) are very important to that smoker. It reveals to both provider and smoker which specific reason or reasons to quit (health, embarrassment to smoke, and social pressures) are very important to that smoker. Understanding the smokers decisional balance gives a snapshot of the state of mind of the smoker and of opportunities to advance along the spiral of change.2

It is possible to either ask people about their reasons to smoke and their reasons to quit in a clinical interview or let them complete a decisional balance scale while they are in the waiting area. We find it is easier to have them complete a decisional balance scale while they wait. It gathers more information more quickly. It creates a moment for reflection and removes the emotional stimulation of having to explain, for example, their pleasure from smoking to their doctor. Most smokers welcome filling it out.

The decisional balance scale developed by Prochaska et al (Table 5)6 does not explicitly measure smoking to reduce negative affect. We include items to ask if smoking gives smokers a lift when they are down. We include a question about whether they have low spirits or mood.

454 DM, July 2002

For the precontemplator this evaluation has 3 possible benefits. First, it can give the provider empathic insight into the smoker by making it easier for the provider to see in a nonjudgmental way some of the obstacles of quitting for that individual. Second, it can give the smoker confidence that the provider will be a sympathetic listener. Third, by establishing a supportive point of view that it is normative to have both reasons to smoke and reasons to quit, the evaluation creates an opportunity for a precontemplator to let down their defenses and identify which reasons to quit are important to them. Thus, the evaluation becomes a stage-specific, consciousness-raising intervention.

For the contemplator, this evaluation has 4 similar possible benefits. First, it can give the provider empathic insight into the smoker’s conflicting and loud internal voices, one saying, “smoke,” and the other saying “don’t smoke.” Second, it can give the smoker confidence in the provider’s sensitivity. Third, the specific reasons to smoke can be valuable information in implementing a coaching strategy (see section below on moving from contemplation to preparation). Fourth, the evaluation may be an opportunity for the contemplator to acknowl- edge those two voices, see them objectively, and realize that all smokers go through this stage. If they did not have reasons to smoke they would have already quit. Seeing the conflict more clearly, the smoker may be able to listen to the content of the conflict with less anxiety than the conflict usually stimulates. Reducing anxiety may enable the contemplator to appreciate the importance of reasons to quit, and more easily answer the question, “What do I really want to do about my smoking?”

For the person in preparation, the reasons to smoke are very important to catalogue the preparedness to cope with quitting. The most-valued reasons to quit are useful for future recollection when the going gets tough.

In collecting reasons to smoke and quit by clinical interview, there is a subtle, but important difference in how to raise the reasons to smoke and quit for precontemplators, contemplators, and those in preparation. Offering the opportunity to the precontemplator to first say, “Smoking is important to me because . . . ,” and, after listening, asking them to complete the sentence, “Quitting smoking would be important to me because . . . ,” gives the smoker the belief of being heard and the opportunity for consciousness-raising. For contempla- tors, asking, “What are your reasons to smoke and what are your reasons to quit?” gives them the opportunity to become aware of the

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TABLE 5. The decisional balance scale

The following statements represent different opinions about smoking. Please rate how important each statement is to your decision to smoke according to the following 5-point scale: 1 = Not important; 2 = Slightly important; 3 = Moderately important; 4 = Very

important; 5 = Extremely important

1. Smoking cigarettes is pleasurable. 2. My smoking affects the health of others. 3. I like the image of a cigarette smoker. 4. Others close to me would suffer if I became ill from smoking.

*5. I am relaxed and therefore more pleasant when smoking. 6. Because I continue to smoke, some people I know think I lack the character to quit. 7. If I try to stop smoking I’ll be irritable and a pain to be around. 8. Smoking cigarettes is hazardous to my health. 9. My family and friends like me better when I am happily smoking than when I am

miserably trying to quit. *lo. I’m embarrassed to have to smoke.

11. I like myself better when I smoke. *12. My cigarette smoking bothers other people. *13. Smoking helps me concentrate and do better work. *14. People think I’m foolish for ignoring the warnings about cigarette smoking. *15. Smoking cigarettes relieves tension.

16. People close to me disapprove of my smoking. 17. By continuing to smoke I feel I am making my own decisions. 18. I’m foolish to ignore the warnings about cigarettes. 19. After not smoking for a while a cigarette makes me feel great. 20. I would be more energetic right now if I didn’t smoke.

Scoring pros 1,3,5,7,9,11,13,15,17,19 (odd numbers) cons 2,4,6,8,10,12,14,16,18,20 (even numbers)

Reprinted with permission from Velicer WF, DiClemente CC, Prochaska JO, et al. J Pers Sot Psycho1 1985;48:1279-89. Available online at http://www.uri.edu/research/cprc/Measures/ Smoking07,htm. *Included for intervention programs.

loud voices on both sides. For persons in preparation, the important focus in a clinical interview should be on the reasons to smoke, as a part of preparation on how to cope with quitting.

Research has shown that nearly all smokers are aware of the major health risks of smoking.22 Decisional balance scales show that some of these risks are important to precontemplators, and more are important to contemplators. Understanding a smoker’s decisional balance can be a chance to hear the smoker, to measure understanding and knowledge, and to prepare to coach the smoker toward change. In Table 6, the role of evaluation of decisional balance is summarized.

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TABLE 6. The role of an evaluation of decisional balance

An opportunity for empathy for the provider. An opportunity to build the smoker’s confidence in the provider’s understanding of his/her

needs. An opportunity for reflection for the smoker.

For consciousness-raising, for the pre-contemplator. For perspective-taking, for the contemplator. For planning to cope, for the person in preparation.

Determining Self Efficacy/Temptation. Asking the questions on the TMC self-efficacy/temptation scale (Table 7) is part of our evaluation for persons in preparation or action. In our experience, it is equally easy and successful to ask these questions by clinical interview or by paper-and- pencil questionnaire while waiting. After identifying difficult situations and those in which the smoker has low confidence, we identify the ideas that the smoker has about alternatives to smoking.

The situational self-efficacy scale can be administered to a precontem- plator. Whereas it is not of particular relevance to someone who has no intention of quitting, its nonjudgmental quality offers an opportunity for precontemplators and contemplators to take a better look at themselves (consciousness-raising, with or without self-re-evaluation). For people in preparation, it is an opportunity to understand the notion of trigger- response and to begin identifying tempting situations as part of preparing to manage them.

We believe that learning effective tools to help smokers cope with the urge to smoke is critical to their success. The omission of this component is an important limitation of the self-help educational materials. The self-help model has been primarily educational, but has not promoted skills building. We have developed a series of experiential exercises for people who smoke that are on the basis of an approach called “mindful- ness.“23 Mindfulness is moment-by-moment awareness of your own experience; in this case, the urge to smoke. Mindful awareness at the time of an urge to smoke is awareness without criticism of self or others, without wishing it were not there, and trusting that if you do not hold on to it or try to suppress it that it will pass in a time frame with which you can learn to live. We use these exercises to build skills to manage the urge to smoke. We use other mindfulness-based, stress-reduction tools to help people who smoke cope with their stress, in general. There are many stress-management tools that help people successfully cope with urges. Becoming familiar and comfortable with a few has been extremely valuable to our ability to work efficiently with smokers in primary care.

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TABLE 7. Smoking: self-efficacy/temptation

Listed below are situations that lead some people to smoke. We would like to know how tempted you may be to smoke in each situation. Please answer the following questions using the following 5-point scale:

1 = Not at all tempted; 2 = Not very; 3 = Moderately; 4 = Very; 5 = Extremely tempted

1. With friends at a party 2. When I first get up in the morning 3. When I am very anxious and stressed 4. Over coffee while talking and relaxing 5. When I feel I need a lift 6. When I am very angry about something or someone 7. With my spouse or close friend who is smoking 8. When I realize I haven’t smoked for awhile 9. When things are not going my way and I am frustrated

Scoring: Positive affect/social situation = 1, 4, 7 Negative affect situations = 3, 6, 9 Habitual/craving situation = 2, 5, 8

Reprinted with permission from Velicer WF, DiClemente CC, Rossi JS, et al. Addictive Behav 1990;15:271-83, and Cancer Prevention Research Center, University of Rhode Island. Available online from http://www.uri.edu/research/cprc/Measures/Smoking02.htm.

We are currently testing the capability of the mindfulness-based, skill-building exercises to increase the effectiveness of the TMC com- puter system. We describe some of these skill-building exercises in detail as part of coaching strategies. In Table 8, the evaluation of temptation and self-efficacy toward the urge to smoke is summarized.

Determining Efficacy of Prior Strategies Used in Quit Attempts. We evaluate prior strategies for moving along the spiral of change and circumstances of prior relapse by clinical interview. We do this evaluation primarily with smokers in our consultation clinic for smoking cessation. We use only very small bits of this kind of questioning with the smokers in our primary care practices.

We ask smokers how they got ready to quit. Whether they are contemplators, in preparation, or in action, we ask them how they got here. What have they done to get ready? We look for consciousness- raising, emotional arousal commitment, self-re-evaluation, or any other process we can identify (Table 9).

We ask them if they have quit before. We ask them the details of prior quit attempts: “When did they occur?” “Did you prepare? If so, how?” “Did you cut back slowly or quit cold turkey?’ “How long did you stay off cigarettes?” “What was that like for you?” “What did you learn from the time you were off cigarettes?’ “What did you learn about your smoking, and about other things ?” We aim to identify countering or substitution, rewards, helping relationships, and environmental control.

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TABLE 8. Evaluating the urge to smoke and the resources to counter the urge for persons in preparation or action

Identify difficult situations. Identify confidence dealing with those situations. Identify smoker’s known alternatives for these situations. Learn brief stress-reduction management tools to teach people who smoke.

TABLE 9. learning what the smoker has done in this and prior rungs in the spiral of change

What did you do to get to where you are now? What did you learn from the last quit attempt? What did you learn from the relapse? Identify “I can’t,” or low self-esteem around quitting and guide self-reevaluation.

We also ask: “What were the circumstances of your relapse?” “Try to remember back to the first cigarette after that quit attempt. What was going on?” “ After the first one, what were you thinking about smoking?” “What did you learn going back to smoking?’

We aim to identify successful strategies that the smoker used along the previous rung of the spiral of change and interpretations of experiences that are holding them back and are in need of cognitive reframing. We are looking for the message, “I can’t,” in which case we talk about the self-fulfilling quality of the attitude of helplessness.

In general, in our primary care practices, we do not methodically review particular strategies that smokers have used in the past. We use the lessons of the TMC for matching processes to stage (see below). Still, we have included the approach because we learn so much about smokers’ experience when we ask these questions in our consultation-based smoking cessation visits. It is always amazing to listen to the detail that people remember about their smoking cessation attempts! The lessons have made us more efficient in the practice of primary care, office-based interventions for smoking cessation. A less textured awareness could be cultivated by administering the items in the processes of change scale (Table 1O).24

Stage-sensitive Strategies for Coaching People Who Smoke

It is simpl.er to give a universal structure to evaluate smoking than it is to give a universal structure for coaching people who smoke. Like raising children, there is a great deal of evidence about professional coaching of behavior change, but no matter how much training people have in the

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TABLE 10. Smoking: processes of change questionnaire [short form]

The following experiences can affect the smoking habits of some people. Think of any similar experiences you might be currently having or have had in the last month. Then rate the FREQUENCY of this event on the following 5-point scale.

1 = Never; 2 = Seldom; 3 = Occasionally; 4 = Often; 5 = Repeatedly 1. When I am tempted to smoke I think about something else. 2. I tell myself I can quit if I want to. 3. I notice that nonsmokers are asserting their rights. 4. I recall information that people have given me on the benefits of quitting smoking. 5. I can expect to be rewarded by others if I don’t smoke. 6. I stop to think that smoking is polluting the environment. 7. Warnings about the health hazards of smoking move me emotionally. 8. I get upset when I think about my smoking. 9. I remove things from my home or place of work that remind me of smoking.

10. I have someone who listens when I need to talk about my smoking. 11. I think about information from articles and advertisements about how to stop smoking. 12. I consider the view that smoking can be harmful to the environment. 13. I tell myself that if I try hard enough I can keep from smoking. 14. I find society changing in ways that makes it easier for nonsmokers. 15. My need for cigarettes makes me feel disappointed in myself. 16. I have someone whom I can count on when I’m having problems with smoking. 17. I do something else instead of smoking when I need to relax. 18. I react emotionally to warnings about smoking cigarettes. 19. I keep things around my home or place of work that remind me not to smoke. 20. I am rewarded by others if I don’t smoke.

Reprinted with permission from Prochaska JO, Velicer WF, DiClemente CC, et al. J Consult Clin Psycho1 1988;56:520-8, and Cancer Prevention Research Center.24 Available online at the Web site: http://www.uri.edu/research/cprc/Measures/SmokingOl.htm.

practice, no two people will be comfortable with the exact same approach. And, as we have said many times, change occurs over time; really, no two people cover the exact same ground.

As authors, we have studied the TMC together and had hours of discussion during the years about interventions. However, an observer watching each of us would see very different pictures. What would be constant throughout would be the timing of promoting processes.

The final sections of this article are not intended as a cookbook of recipes for coaching your patients about smoking cessation. Rather, we hope our observations will offer you a description of ingredients with which to make your own recipes for your own practice of professionally coaching smokers. The following comments build on the TMC as a tool for evaluating smokers and understanding the pathophysiology of smok- ing cessation.

The overall goal is to promote more rapid progression along the spiral of change and to increase skills for mastering stage-specific competen-

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ties. In the TMC, this implies facilitating a shift in decisional balance toward the decisional balance characteristic of the next stage. Concretely, we try to promote increased importance of individual reasons to quit smoking, lowered importance of the reasons to smoke, or both. In the TMC, movement toward cessation also implies facilitating a progres- sively increasing self-efficacy in tempting situations. Guided by the TMC, we attempt to facilitate the step-by-step shifting from precontemplation to maintenance by matching the processes we encourage to those used by self-changers in similar stages. We vary the intensity of stage-based coaching to the circumstances of our clinical work. If the time is limited, we may emphasize only one of the building block concepts of decisional balance, self-efficacy, or processes of change. If we think we have more time during a single visit, we may work more intensively with a single building block or we may work with multiple building blocks.

We do not coach the small number of persons we believe are nondefensive, fully informed, committed smokers. We believe that would not be patient-centered care. Instead, we regularly revisit their commit- ment to smoking. We encourage them to continue to reconsider their commitment. If their commitment wavers and they enter the cycle of change, we recommit ourselves to coaching them from the stage at which they enter toward termination from smoking.

Coaching the Precontemplator Toward Contemplation: Increasing Reasons to Quit and Honoring the Reasons to Smoke. Knowing someone is in precontemplation informs a coach to facilitate experiential processes with an emphasis on consciousness-raising (Table 11). The intention is to facilitate an increase in the importance of reasons to quit. Understanding what is important about smoking and about quitting informs the content area for coaching the particular precontemplator. Avoid preaching about those reasons to quit that the smoker ranks as very important. Target those things that are a little less important for increases. Understanding that detachment or combativeness is a reflection of wanting to quit, although not immediately, informs the style of coaching.

Acknowledge that the smoker does not intend to quit in the foreseeable future, but that the topic of smoking remains part of the encounter. Be clear that your goal includes understanding the patient’s smoking and helping the patient understand more clearly his or her reasons to smoke.

Work with consciousness-raising. Raise consciousness by honoring the importance of reasons to smoke while noting that this does not make the reasons to quit false. For example, if stress reduction is important and the health of others is not very important, acknowledge that smoking helps a lot with stress, but that their child’s asthma, or overall health, is still

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TABLE 11. Processes of change’

Process Examples related to smoking Cross-

reference with Table 10

Experiential processes Consciousness-raising

Emotional arousal

Self-re-evaluation

Commitment

Behavioral processes Countering or substitution

Rewards Environmental control

Helping relationships Social liberation

Notice reasons to smoke and reasons to quit

Seek information about smoking or cessation

Respond to the illness of a smoker with concern and a desire to change

Weigh the pros and cons of smoking Think about the future implications of

smoking Set a quit date Discuss intention to quit with family and

friends

Substitute exercise, relaxation techniques, water, or a distraction for cigarettes

Save money, praise from others Clean the home Spend more time in no-smoking areas Allow others to support and guide Get involved in tobacco control

Items 4, 11

Items 7, 18

Items, 8, 15

Items 2, 13

Items 1, 17

Items 5, 20 Items 9, 19

Items 10, 16 Items 3, 14

affected by second-hand smoke. Or focus on the patient’s cough, chest pain, claudication, or gastric symptoms. Help them see that they do not have to block out the truthfulness, or even the importance, of the reasons to quit to honor the truthfulness and the importance of the reasons to smoke. They can do both!

For the precontemplator who smokes for pleasure, it is almost impossible to help this individual if you cannot honor the pleasure derived from smoking. People do not smoke because they are ignorant of the harms, but because the benefits are important to them. You can invite the precontemplator to describe that pleasure to you and see if it opens a door.

When giving direct information about smoking and health, highlight the benefits of quitting, as opposed to the risks of smoking (Table 12).22*25 The benefits of quitting have been less well publicized, so this avoids preaching the known to the knowing. It can correct a myth of older, established smokers that the damage is done and there are no gains from cessation. Financial, environmental, social, or aesthetic concerns may all be legitimate reasons to quit smoking.

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TABLE 12. Benefits of quitting22,25

Decreased mortality-for both younger and older smokers. Decreased cancer incidence--lung, larynx, oral cavity, esophagus, and bladder cancers. Decreased cardiovascular diseases:

Coronary artery disease-decrease risk of myocardial infarction, improved myocardial infarction outcomes. Peripheral vascular disease-decreased risk and symptoms. Stroke-decreased risk.

Respiratory diseases and function: Diminished respiratory symptoms, including cough, wheeze, and dyspnea. Delayed onset of chronic obstructive pulmonary disease. Diminished mortality from pneumonia and influenza.

Improved healing of gastric and duodenal ulcers. Decreased days of work lost because of illness. Reduced risk of low birth-weight babies (for preconceptual or first trimester cessation). Decreased risk of household members to second-hand smoke. Other benefits:

Financial savings. Cleaner personal environment. Ease of navigating non-smoking environments. Improved senses of taste, smell, and sexual function. Increased ease and decreased conflict with nonsmokers.

Promote emotional arousal . . . but with caution. There is a paradox, here. Without taking the harms of smoking personally, there is not good reason to consider quitting. But stimulating a precontemplator can lead to defensiveness or closing off. Listening to the lungs of someone with a cough, and asking, “Are you still smoking?’ can either motivate move- ment or rigidify stability. “You might have more energy if you weren’t smoking,” or “Couldn’t you use the extra money each month?” are less stimulating kinds of prompts for emotional arousal in persons for whom energy or finances are important. Paying attention to the tone and the content of your comments, watching your body language, and listening to the comments of the patient will teach you both what you do well in this way, and what the particular smoker can tolerate.

As precontemplators develop a little more strength of importance in their reasons to quit, there may be opportunities for self-re-evaluation. This can be a time to invite a precontemplator in motion to examine the balance of their priorities regarding the advantages and disadvantages of smoking. This can be a time for reassessing the support for smoking from tobacco companies, or the sense of pride that others have gained from quitting.

In our work with medical residents who are learning to coach smokers, we suggest asking people in precontemplation to use the time before their

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TABLE 13. Coaching the precontemplator

Honor the lack of readiness to quit, but keep the topic on the table. Target those reasons to quit that have a 2 or 3 on the Likert Scale, not those that have a

0 or 5. Promote increased reasons to quit through consciousness-raising, emotional arousal. Highlight the compatibility of reasons to smoke and reasons to quit. Highlight the benefits of quitting rather than the risks of smoking. Cautiously promote emotional arousal. See if there are opportunities for dramatic relief and self-reevaluation. Give homework between visits: Notice what you dislike about smoking. Pay attention to underlying problems and solutions to stress and concentration deficits.

next visit to notice any dislikes they have about smoking. We teach residents to ask people to pay attention to the negative physical effects of smoking. This assignment engages smokers with several processes of change. Taking the assignment is a form of commitment that smokers may be comfortable making. Noticing one or more negative effects of smoking raises their consciousness. This awareness, if of personal concern, may have the effect of arousing their emotions. The emotional arousal increases the importance of reasons to quit, shifting the decisional balance. The shift in decisional balance, in turn, builds more commitment.

If precontemplators smoke to reduce stress or to concentrate, we talk about stress management and difficulties with concentration without relating these topics to smoking cessation. We acknowledge their need for tools for stress control and concentration. We support them with the information that stress and concentration are the most important reasons for smoking, and assure them that the effects are real. We may take the opportunity, at another time, to remind them that this does not invalidate the truthfulness or importance of the reasons to quit. We inquire about issues with concentration as diagnosticians looking for structural, meta- bolic, or psychologic causes. We look to see if their reliance on smoking reflects depression or home situations needing medical or social-service attention. We appeal to their self-interest to improve their daily experi- ence. We see if they are interested in stress-reduction tapes or courses. This can be a particularly valuable entry to discussion of a root cause of smoking without mentioning smoking for a person who is very defensive about the behavior. In this case, we may even put the problem smoking on a back burner. Table 13 reviews suggestions for coaching precontem- plators.

Coaching the Contemplator to Preparation: Facing and Addressing Reasons to Smoke Through Skill Building. Knowing someone is contem- plating quitting informs a coach to facilitate experiential processes with

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an emphasis on committing to quit in the face of conflicting internal voices of “smoke” and “don’t smoke.” Understanding what is important about smoking informs important content for coaching the particular contemplator. Target the most important reasons to smoke for small decreases in their importance. Secondarily, target the least important reasons to quit for small increases in their importance. Understanding that anxiety, fear, and uncertainty reflect the dual voice of the contemplator informs the style of coaching.

Contemplators are easily stimulated, as Daniel describes in part 1 and Zena describes in the next section. Suggesting additional reasons to quit or frightening them about smoking may fuel their anxiety. Fear may stimulate increased smoking. This is one way to understand why the empiric work of the TMC has shown that smokers most often get stuck in the move from contemplation to preparation. Clinically, this may mean that contemplation is the most difficult stage to coach. Inviting self-re- evaluation, honoring fears, clarifying the nature of commitment, intro- ducing behavioral processes, and helping smokers face their reasons to smoke are coaching opportunities that we use with contemplators.

Invite self-reevaluation. Suggest a self-reflection of, “Why I started and why I smoke now.” For those more than 35 years old, invite a reevaluation of their vulnerability and their hopes for health and longev- ity. Has the smoker lost the thrill or appeal of smoking? Does he or she believe himself or herself to be trapped by smoking? Has the importance of some of their reasons to smoke lessened, on their own, with time?

Teach contemplators that the experience of those who have quit confirms one part of their fear (quitting is hard), but challenges another (quitting is unlikely to be successful). Remind them that thousands of people quit each year, and that there are at least as many former smokers than active smokers. Demystify the belief that there are people who quit with no effort. This is not usually the full truth. Primary care providers can share both stories of how other smokers have changed and stories of how others waited too long.

Invite contemplators to see that smoking reproduces physiologically some of the experience of distress. Inform smokers that many who quit report less perception of stress after 6 months. If the stresses are symptoms of inadequate sleep, anxiety, or clinical depression, discuss alternate strategies to treat these symptoms. Educate contemplators that when successfully treated, more energy and optimism may follow.

Invite contemplators to notice the effect of smoking on their tension, their concentration and distractability, and their pleasure at key times

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related to smoking: at the moment they begin their ritual of smoking; during the next 2 to 5 minutes after the cigarette when nicotine levels are peaking; and 30 minutes later when nicotine levels are falling. If attuned, they can notice changes in heart rate, respirations, and muscle tension as nicotine rises and falls.

We have used a 5minute guided visualization (see “Visualization of the Unpleasant Aspects of a Cigarette”) to help contemplators who derive a great deal of pleasure from smoking expand their awareness to the unpleasant aspects of smoking. With guidance, the contemplator who smokes for pleasure may be able to see the 2-sidedness of a cigarette; its pleasant and unpleasant qualities. The awareness of the power of the mind to suppress the unpleasant aspect of a cigarette allows self-reevaluation. We understand that finding time for this kind of intervention in our practices will test the creativity of office managers!

Visualization of the Unpleasant Aspects of a Cigarette

Verbally give the smoker the following exercise.

Close your eyes and imagine taking out a cigarette and a match. Imagine lighting the match. Pause and study the flame-its color, shape, vapors-and even feel the heat by imagining placing it close to your skin. Take a single imaginary draw to light your imaginary cigarette. Study the lit tip: the color of the burning paper and plant, the smoke. Compare it with any other smoke and imagine placing the lit cigarette by your face and feel the heat. Take a single puff of smoke into your mouth. Observe what happens to your mouth, especially any heat or drying, then draw and follow that sensation all the way down to your lung.

Let them describe the experience. Draw their attention to the ready access in their minds of the unpleasant aspects of smoking so vividly remembered from the first cigarette many years before. Only a small minority of people we see are not very skillful at this. When they have finished we often compare this awareness of the unpleasant aspects of a cigarette with going from the city to the country and noticing the clean air, then coming back to the city and noticing the unpleasant smell, which fades in only a very few minutes or hours. We encourage smokers to notice the unpleasant aspects of a cigarette the next time they smoke.

Guide them toward commitment. Commitment is a central process of change. It is used increasingly from early contemplation through maintenance. Commitment was highlighted by each of the former smokers we interviewed for “Clinical Vignettes.” Contemplators may believe they lack the willpower to quit smoking. See if they can

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60

FVecontempIation Contemplation

Preparation Maintenance Action

FIG 1. Decisional balance in smokers, “Mount Change”. (Reprinted with permission from Homeostasis.‘)

reframe this as lacking the commitment to quit. The two are very similar, but “willpower” sounds like a characteristic or trait that is largely outside a person’s control. Commitment is understood as something active. Review other commitments they have made, to marriage, family, or work. Remind them that they would not have succeeded in these arenas without commitment.

Encourage specific actions short of cessation to increase their commit- ment. Examples include: decreasing the number of cigarettes smoked each day; making their goal of quitting in the next 6 months known to a trusted friend; and beginning to exercise, meditate, or practice yoga to decrease stress.

Introduce behavioral processes. Many contemplators may get stuck in contemplation as they try to think their way out of contemplation. “If only I had the right reason to quit . . . .” Help the contemplator understand that quitting smoking goes beyond thoughts to behavioral changes. Making small changes, such as cutting back by a few cigarettes a day, delaying the first cigarette, or choosing to spend time in no-smoking environments such as areas of restaurants or public buildings, can all help the contemplator experience the possibility of building on success.

Help contemplators face their reasons to smoke. The move from contemplation to preparation is associated with attaching less impor- tance to reasons to smoke so that the reasons to quit smoking outweigh the reasons to smoke (Figure). Contemplators are often stuck in a dilemma. Because the reasons to quit are deeply important, continuing

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to smoke is stressful. Because the reasons to smoke are also strongly held, stopping is stressful. And cigarettes help them cope, concentrate, or have a moment of pleasant relief from the voices of “smoke” and “don’t smoke.”

Explain the two aspects of the calming effects of the cigarettes. We review the pharmacologic effect of nicotine described in part 1 of this 2-part article. It stimulates a transient release of a host of neurotransmit- ters in the central nervous system, simulating an adrenaline response including heightened concentration. We explain how this feeds on itself by calling for more release of neurotransmitter.

Explain that they will need to accept the loss of the important aspects of smoking to move on toward cessation. This is a good opportunity for them to list the importance of all their reasons to quit and balance them with the importance of their pleasure.

We review how the behavior of smoking is calming and heightens concentration. Smoking is a ritual that includes taking a break, lighting a fire, and changing posture and breathing patterns. The behavior of smoking is a meditation. It simulates the relaxation response, slowing the pace of life for a few minutes and giving a sense of alertness, renewal, and calm (see “An Observation”).

We sometimes teach an exercise that focuses on awareness of breathing (see “Experiencing Relaxation Through the Behavior of Smoking”). The experience of relaxation without smoking may give the contemplator confidence to advance to the next stage. Before you try this on a patient, we recommend that you practice on your own with a friend or members of your office staff.

An Observation on the Relaxing Quality of the Behavior of Smoking

This awareness of the relaxing quality of the behavior of smoking was impressed on me (D.G.) one beautiful spring morning when I changed trains in downtown Chicago. I had to cross a plaza in which there were lovely planters brimming with blooming tulips. There was warmth in the morning air for the first time in nearly half a year. In the plaza, filled with commuters walking with a quick pace to their office buildings, there were only a few people who seemed to be soaking in the day. They were the people who sat still, smoking before they went to work in their buildings. You could see stark differences in the body language. The hustling commuters were propelled forward, almost bursting out of their bodies, with their shoulders up near their ears. The people taking a moment to smoke a cigarette and capture the glorious spring morning seemed more contained within their bodies and their shoulders had a chance to relax.

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Experiencing Relaxafion Through the Behavior of Smoking

Begin by noticing whether or not you have a desire for a cigarette right now. If you do, give yourself a score from 1 to 10 that describes how much you want a cigarette right now. Are you tense anywhere in your body? If you are, give yourself a score of 1 to 10 that describes the amount of tension at that spot. Are you distracted? If you are, give yourself a score of 1 to 10 that describes the level of distraction.

Pause 5 to 10 seconds. Now, whatever position you are in, notice your posture. Once you have,

take the position that you would take if you were going to smoke a cigarette right now. Did you change your position? Is it a more relaxed posture?

Stay in the position in which you smoke. If you are comfortable with it, close your eyes. Now, notice the movement of your chest wall as you breathe in. Notice the movement as you breathe out. Now, if you can, breathe in as though you were drawing on a cigarette and breathe out as though you were blowing out smoke. Observe the movements in your chest now. Are they deeper? Smoother? Is your belly moving more?

Continue to inhale and exhale as though you were smoking for as long as you spend smoking a cigarette. When you are done with inhaling and exhaling the way you do with a cigarette, open your eyes.

Now, again, give a score of 1 to 10 to your desire for a cigarette. Notice any change. If you noticed any tension in your body when you started, notice any change in tension now. For the level of distraction, notice any change.

Many people are pleasantly surprised to experience a decreased desire for a cigarette after this exercise. Many are also calmer, more relaxed, and more focused. We have come to believe that the behavior of smoking is a form of meditation, which is a cornerstone of nearly all stress reduction. The exercise you just completed is one way to learn that you can reduce your stress without cigarettes, and, therefore, without the tar and nicotine that comes with them. You can practice this on your own.

We invite the contemplator to find alternate breaks. Suggestions include taking time for a snack, a hot drink, or a glass of water, stretching or vigorous exercises, a warm bath, a brief telephone call to say hello to a friend or family member, a walk outside, or bringing something soothing into their environment such as a lit candle or a vase of flowers, These each offer stress reduction, concentration, and pleasure, much like the behavior of smoking.

Knowledge, skills, and self-re-evaluation can reduce the noise from the debate within and bring the contemplator the confidence, calmness, or presence of mind to deepen commitment to stopping smoking. Sugges- tions for physician interventions for contemplators are summarized in Table 14.

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TABLE 14. Coaching the contemplator

Avoid increasing reasons to quit without lowering the importance of reasons to smoke. Invite self-reevaluation. Acknowledge that quitting is hard, but reveal that quitting is possible. Guide toward commitment. Introduce behavioral activities. Focus on reasons to smoke. Teach the relationship between stress and smoking. Teach the meditative quality of smoking.

Coaching the Smoker in Preparation Toward Action and Mainte- nance: Managing the Reasons to Smoke by Mastering the Urge to Smoke Through Skill Building. A great many people in preparation quit smoking on their own or readily with the help of physicians. As all primary care doctors know, there are also a sizable number of smokers who intend to quit in a month, have quit for at least 24 hours in the past year, but do not respond as readily to the usual suggestions. Remembering that, on average, people take 4 attempts to quit can cultivate patience. In some communities there are skilled counselors to support these smokers to reach their goal more quickly.

In this final section of this chapter, we will share some of our experiences coaching smokers in preparation. Our coaching experience comes from our primary care practices and dedicated coaching sessions. In primary care, we generally coach people briefly, in keeping with the pressures of busy practices. In the smoking cessation clinic, we see people for 8 to 10 half-hour visits during 3 to 6 months. There is little work we do more rewarding than smoking cessation counseling. In our clinics it has taken 60 to 100 patients before our physicians are at ease with coaching the most challenging smokers. Having done this work for many years, we occasionally work more intensively with our primary care patients, but rarely with more than one person at any time. We will draw on this experience as it applies to our work as general internists.

We classify people who we see in primary care into 3 groups. There is a large group of smokers who are intending to quit and ready to work who find the pace and limited intensity of physician-delivered smoking cessation helpful. There are 2 groups who do not respond readily. They include the group of those who are intending to quit, but are not ready for the hard work; and the group of those who are prepared and ready for the work, but the primary care-based interventions are not enough.

Zntending to quit, ready to work. Coaching those prepared to take on the hard work of smoking cessation is more similar to other aspects of clinical

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care than coaching contemplators and precontemplators. Those in prep- aration are committed and they are ready for behavioral processes, the nuts and bolts of actually stopping smoking. There is an easy alliance between coach and smoker. The smoker wants your help. You have likely read the national guidelines,93’0 which we reviewed previously, and the many quick tips that can be implemented with or without over-the- counter or prescription pharmacotherapy. The smoker in preparation can use the pharmacologic agents for support and to learn to regulate urges by making them more tolerable. Luther describes the benefits of medication use in his quit attempt on page 480. A supportive doctor/coach gets positive feedback in the form of appreciation. By identifying the most important reasons to smoke and situations where confidence is low to resist smoking, the coach can aid the smoker with a forewarning of pitfalls.

Smokers in preparation are often open to stress reduction. We have developed a series of brief exercises that are specific to smokers, including the exercise described above, but any stress-reduction tools can be taught by knowledgeable physicians or by referral. These tools include relaxation breathing, meditation, yoga, or progressive muscle relaxation.

Commitment can be operationalized in preparation by helping smokers set a quit date and recommending that they inform family and friends of the quit date. The behavioral processes of change are fully implemented when smokers in preparation take action. The behavioral processes include countering or substituting, environmental control, rewards, and helping relationships. There has been a great deal of continuing education and written messages to physicians about reviewing specific environmen- tal changes (cleaning the car and house, avoiding high temptation/low confidence situations); setting up a system of rewarding oneself; substi- tuting water, diet suckers, celery, or sucking a lemon at the time of a craving; and using nicotine replacement for managing withdrawal on a quit day or prescribing bupropion for reducing craving to manageable levels. In the “Clinical Vignettes,” former smokers describe the many different ways they worked with behavioral processes to help them quit smoking. Physician follow-up by telephone at the end of the first and fourth week of the quit attempt may help smokers sustain their quit attempt. Table 15 is a summary of suggestions for coaching smokers in preparation.

Intending to quit, but not ready for the work. Typically, these people seek your opinion on pharmacologic solutions to cessation, often after having unsuccessfully tried over-the-counter nicotine replacement. It is as though they are searching for a magic bullet.

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TABLE 15. Coaching the smoker in preparation

Operationalize commitment by helping set a quit date. Recommend telling family and friends the quit date. Offer strategies consistent with the behavioral processes of change:

Countering or substitution Environmental control Rewards Helping relationships

Identify and help anticipate behavior change for the most tempting smoking situations. Teach (or refer for) simple stress-reduction techniques. Use of pharmacotherapy when appropriate. Follow-up 1 and 4 weeks after the quit date. For more information on working with those in preparation, see Chapter 1 or the Public

Health Service guidelineg,10

This profile reminds us that the stages of change are not perfectly correlated with decisional balance, processes of change, or self-efficacy/ temptation. It is helpful to administer one, or all of, the 3 scales described. We see people who express intent to quit but are interested only in pharmacologic therapy with decisional balance compatible with contem- plators, and occasionally with precontemplators. Many will be anxious during discussion of a plan to quit, and others will be defensive about their plan. Often these people have very low confidence in tempting situations and even believe that it is the cigarette controlling them rather than them smoking the cigarette. They see themselves as low in willpower.

The evidence from the naturalistic study of the TMC on patterns during the 2 years of follow-up suggests that these smokers are less likely to stop and have a higher risk of relapse than smokers who are ready to engage in the behavioral processes. We also hear many anecdotes from people with this profile who have become cynical of their ability to stop smoking.

We approach these persons as a variation of contemplators, because, unlike typical contemplators, they are often defensive. As described in the section on contemplation, we try to promote experiential processes, like self-re-evaluation, to deepen commitment; we attend to reasons to smoke and alternate strategies; and we invite them to face the hard work. We ask them to substitute the word commitment for willpower in the statement, “I don’t have enough willpower.”

We work with their defensiveness by helping them understand that we know how much they want to quit, but also how important their smoking is to them. If it were not important they would be having more success. They may see themselves as weak and incapable with respect to cigarettes and feel ashamed. We help them see that making a commitment to quit

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smoking gives people the courage to act in the face of fear and to do so with hope as opposed to shame or self-doubt.

Sometimes we simply reason with this group, a form of consciousness- raising. We ask them what change in their life was ever simple and what change ever occurred without commitment. People tend to understand commitment and have had the experience of making commitments in their lives. They have acted on a commitment to a spouse or significant other, to children, or to an aging relative. They have made commitments at work or at school. They may have made commitments to themselves, changing behaviors of drinking, gambling, eating, or being sedentary. Building on these experiences, they can see the need for commitment. We review the fact that the urge to smoke does not disappear. It may fade and then return without warning. We ask them to reflect on how they will deal with that urge when it surprises them in 6 months if they are not prepared to work with it now. For the more philosophic, we try to help them see that the urge is a valuable learning opportunity.

We use pharmacotherapy differently. We use it as an opportunity for self-re-evaluation. What are they seeking? Are they finding it? Might it be they need to deepen their commitment? Are they smoking to regulate depression? Are they having difficulty coping with the stresses in their lives? Are they not really as prepared as they wish they were to give up their friend or their main source of pleasure?

Initially, if they leave with a prescription, we ask that they commit to returning for a follow-up visit in 2 to 4 weeks. At that time, we again work with building their commitment on the basis of what they have learned. On return, if they are not progressing, we often recommend return to a smoking cessation treatment program.

Prepared, ready for the work, but the consensus suggestions are not enough. These people are recognized by their lack of success with the behavioral interventions. Their decisional balance is typical of successful transition from preparation to action (the importance of reasons to quit outweighing reasons to smoke), but they believe they lack willpower, ie, commitment, and their confidence for dealing with situations is low. They may use cigarettes to elevate their mood. These people are, in our opinion, candidates for referral to a special smoking cessation treatment program.

In that program we take more time with them relative to the pace of primary care. We promote self-reevaluation of their low confidence. In the first week, we might have them smoke on an hourly schedule. When they come back, they frequently report, “I did terribly,” even when they made important strides. We help them put their slips in perspective. We remind them that no human ever learned to walk without slips and that

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none ever said, “I can’t,” when they slipped. We work more intensively with stress-reduction techniques for those who smoke to relieve stress. We spend more time with the exercises described above for contempla- tion. We give them homework to practice the exercises on their own. We ask them to commit to coming even if they believe that they have let themselves down. We call them back in 6 months or a year if they drop out.

We focus their attention on managing the urge to smoke. We help them see that it is a voice in their own mind saying, “smoke.” We spend time teaching them about using distraction (reading, television, or a project), substitution (water or candy), relaxation techniques, and patience while waiting for the urge to pass. We encourage them to truly face their urge. We think of a story from Rachel Naomi Remen’s book Kitchen Table Wisdom,26 about courage as a way to understand what it takes to face the urge.

As a child, Dr Remen had an uncle who was decorated in World War II. He had saved many lives under treacherous conditions. One day, thinking he could teach her not to be afraid of the dark, the 7-year-old Dr Remen told him how brave she thought he was and asked how he learned to never be afraid of anything. His response, she writes, was, “Smiling, he told me that this was far from the case, that he had never been more frightened than ever before in his life.” He taught her that “being brave does not mean being unafraid. It often means being afraid and doing it anyway.”

Many people who smoke are fearful of their urge to smoke. The lesson of Dr Remen’s story is that bravery can only occur in the presence of fear. When people find the courage to face an urge for the 10 to 20 minutes it usually lasts, they often find that the period of discomfort is, indeed, tolerable and that it can be faced.

Clinical Vignettes In part 1 of “Understanding People Who Smoke . . .,” there were two

case vignettes, Daniel and Susan, interspersed throughout the issue. Daniel and Susan quit on their own, without help of physicians. In part 2, we will present two more case histories of individuals who worked with physicians to help them quit. They will talk about the challenges they faced: what made them feel good and what made them feel bad, and about the places they got stuck and their breakthroughs. Their words reflect two unique pathways to cessation, but beneath their distinct voices you will hear each describe progress through the stages that are the bulding blocks of the TMC.

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Zena Zena is a 37-year-old female who usually smoked 20 cigarettes a day.

She started to smoke at age 11. “I thought it was pretty,” she says, “because women on television all smoked and they were all glamorous. Also my sister-in-law was very pretty and she smoked. That’s what attracted me to smoking.”

Initially, she would sneak cigarettes in the bathroom. At age 12, she smoked 3 cigarettes on a daily basis, often with peers. Slowly her smoking increased. At age 15, she believed that she could no longer control when she wanted to have a cigarette. At about the same time, she began to smoke openly with her family.

Zena had 3 quit attempts. She quit for half a day at age 18, wanting to appease a boyfriend who did not smoke and did not like cigarette smoking. This first quit attempt ended when, “I went out and I was drinking and I wanted a cigarette.” At age 27 she gave birth to her daughter. Her daughter had a low birth weight and had respiratory problems throughout her childhood. Problems with her daughter’s health and the prompting of doctors who cared for her daughter stimulated her interest in quitting smoking. At age 32 she enrolled in the Cook County Hospital Smoking Cessation Clinic but did not follow-up with her clinic appointments. She had started to gain weight and was concerned that if she continued to try to quit, she would gain more weight. At age 36 she returned to the clinic and quit, working with her provider in the smoking cessation clinic with a variety of behavioral interventions. She has been without cigarettes for 8 months.

Luther Luther is a 52-year-old male who smoked 2 packs per day. He

experimented with cigarettes in grade school, smoked more regularly in high school, and became committed to smoking in his second or third year of college. “I loved smoking,” he says. “I fancy myself as a hard-core guy’s guy: sit in the bar rooms, sit in the saloon, smoke cigarettes, drink Jack Daniels. The smoking fit into this silly part of this self-image of mine.” He quit twice. The first quit was while in college, for 2 to 3 months. He relapsed, thinking that, “It was OK for me to go back to smoking. I felt I could quit any time I wanted to.” He quit again 1 year ago. He became motivated to quit after 2 people close to him, his father and a friend, had died of smoking-related illness in the preceding 12 months. His decision to quit also came at a time that he describes as “an

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enormously unhappy time of my life” related to personal affairs. He describes:

The notion of stopping smoking at that moment came to mind first because I thought at such an unhappy stage, it would be good to do something really positive for myself. I wanted to try to do something that would make me feel better psychically more than physically, immediately.

He enrolled in the Cook County Hospital Smoking Cessation Clinic and quit by using transdermal nicotine together with behavioral interventions.

Zena Why smoke? Zena was aware of the stress relieving effects of smoking.

She describes, “If I was upset, smoke a cigarette. Whatever it was didn’t matter any more. It wasn’t that important. It will work itself out.” Zena also describes a meditative quality to her smoking.

I would never smoke around people. I would go in the bathroom and smoke, and just get to myself and be quiet and smoke. . . When I inhaled it was like a sense of comfort. And then when I would exhale it was like relief. . . . I would inhale comfort and exhale calm.

Luther Why smoke? Luther had multiple motives for his smoking: habit,

addiction, relaxation, sensorimotor stimulation, social smoking, and smoking alone. In explaining what he liked about smoking, he says:

There were a few things. Cigarettes in the morning, out of bed, had some physiologic effect to me. They made me feel better. Start with coffee in the morning, cigarette . strong coffee, always felt, “I liked that. . . .” The smoking that stands out in my mind among the times when I smoked was, in some real level I miss, after a meal, while one’s drinking, while one’s consuming alcohol, after sex . . . . I live by myself. I have lived by myself for quite a while. There’s something about . . in the morning, or late at night, sitting in a chair with a book, and a cigarette, and a cup of coffee . . very peaceful, very pleasureful. And then the cigarette part of it just became deeply ingrained. And of course one can do the same things without the cigarette part of it, and I have, and I like that I have. But, if there were no harm associated with the cigarette, I would do it immediately. I would do it again. There’s something about it I like. I just like it. I liked years when it was . sort of a social activity. You smoke amongst people . . . you offer someone a cigarette

you offer someone a light . they offer you a light . you ask can you borrow a cigarette . . . . You know, there was a time, we can remind ourselves that, it sounds kind of funny now, that it was far more common to interact with someone around cigarettes in a positive, social way . . . When I traveled, there are places you go where the social aspects of smoking are especially helpful. It helps you interact with strangers.

When Luther quit smoking, he was aware of “2 parts” to work with to be successful with his quit attempt. There was the “nicotine part,” which

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he described as “a palpable kind of something . . . nervousness . . . edginess that I took to be a physical reaction.” The second part, the behavioral part, is bigger and presents itself to you in many manifesta- tions . . . . All the regular activities that are associated with smoking, the regular behaviors that have become part and parcel of your life; eating, waking up, whatever.

Zena Pathway to cessation. Zena describes a time when she didn’t give

smoking much thought at all. After her attempt to quit smoking as a teenager, she says, “I never thought about it. I just kept going . . . . It just left my mind. I hadn’t thought about it any more.”

Zena seriously began to consider quitting smoking around the time of the birth of her daughter. The dominant process that Zena describes in this period of time is emotional arousal.

I was pregnant with my daughter and I was smoking cigarettes. And I remember sitting here in the county hospital at the obstetrics clinic where they had a picture of a baby with all these tubes on him. And the ad kind of said this is what happens when you smoke. And a week later I gave birth to my daughter, and she looked exactly like the baby on the picture. Low birth weight, all these heart monitors, breathing machines, everything, all these tubes on her. So that’s when it really hit me where I needed to quit. It just hit my heart. Because I hated to see my baby lying there helpless on machines to help her breathe, and oxygen, and heart monitors, all the IVs. It hit my heart. But cigarettes were also like a comfort for me at that time, to help me to deal with everything that was going on . . . I thought about what I had done to my child. This is something I had done to her and I love her and I didn’t want her to die. I wanted her to live a healthy normal life. I was angry. I wasn’t really sad. I had more anger. I was angry at myself for a long time.

For a period of years, Zena remained in contemplation. The emotional arousal led to her making changes in where she smoked and to find ways to protect her daughter from the smoke. All the while she continued to use the cigarettes as a way of reducing stress. Starting from when her daughter was a newborn:

I felt like she’s born now so the cigarettes can’t hurt her. But I did not realize the dangers of the second-hand smoke until years later. . She came home, I continued to smoke, and at 3 months old she developed upper-airway disease. I was back and forth in the hospital at least 3 times a week with her. She was 6 months old and they put her on a nebulizer. So I was at home giving her the neb treatments. I had to give it to her 4 times a day. So, I did that for a couple of years. I continued to smoke. I think she was like about 2 or 3 years old and the doctors asked, “Was there anyone at home who smokes?” And I said, “Yes,” that I smoked. And the doctor said, “You need to stop. No, not stop smoking, you need to go in another room. Don’t smoke around her.” So that’s what I began to do, go in another room to smoke, and after that, that

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worked for a little while, you know, it started to get worse, her asthma got worse. So I went and bought an air filter to filter the air when I would smoke. And that still didn’t work. And I went to the humidifiers and vaporizers and everything to try to accommodate me to smoke.

In contemplation, Zena experienced conflict at times of crisis concern- ing the health of her daughter. When her daughter had an exacerbation of her chronic respiratory condition:

I was in the emergency room 12, 13 hours. They would give her the breathing treatments. And I would say, “I have to stop. I have to stop.” But then I noticed, while I was in the emergency room, I would have to leave from by her side to go outside to smoke, because that was my comfort. It made me feel like everything was going to be all right. That nicotine gave me a feeling of satisfaction. Where nobody, no matter if my mother, my dad, or who was there, I just wasn’t getting it, that calmness that I felt I needed.

The emotional arousal became more intense when Zena’s daughter was 9 years old.

She told me that she was convinced that I wanted her dead. Yes, that’s what she told me, that I wanted to kill her, that I did not love her. And that I just wanted her dead. And I asked her, “What are you talking about?’ And she said, “Your smoking.” And I was like, “Wow, but I go in the bathroom and smoke. I don’t smoke in any other parts of the house. I go in the bathroom and I smoke and I have the fan on, and I close the door when I come out of the bathroom.” And she said, “Every time you smoke I can’t get my breath. I’m coughing. I’m choking.” And that really hit me. And I was, like, “Wow, my baby really thinks I want her dead.” And I called here to get help.

Zena came to the smoking cessation clinic at ages 32 and 36. The quality of her commitment to quit was very different at these 2 times. The first time, her commitment waned when she encountered difficulties.

I don’t think I was really ready. I wanted to. But then when I got into the program, and started, it was like, “Oh gosh, I’m going to gain weight.” And I never wanted to because I’ve always been slim. . . . I didn’t dare want to gain weight. I had fears of getting fat . . . I didn’t quit. I stopped coming to the program. And I continued to smoke.

At the second cessation effort, she describes her commitment in stronger terms. When she started to gain weight and encounter the stresses of her daughter’s health problems, “I started working even harder to quit.” This time she believed that the commitment resided in her heart. “When I started to put it in my heart, ‘OK this is what, you have to do this,’ it started to flourish . . . . Along with that commitment, I noticed that my commitment to other things flourished.”

Zena quit with the help of the smoking cessation clinic. She describes 2 elements of particular importance to her that developed in the clinic. One was setting a quit date for the Monday after Easter, a date

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approximately 2 months away. The second is that she worked with her provider (A.H.), in the interim, on stress and smoking.

I remember I was having a little difficulty and he was teaching me how to breathe. He told me just listen to him and do what he was saying. So I did, with the breathing. And it helped to calm me and to give me comfort. And he said, “How would you like it if I give you this tape and you try at home?’ So that’s what I began to do. In the mornings, I would get up about 5:30, I would pray, and I would do my meditation. So it helped, it helped.

She describes the experience of quitting in the following way:

So I think it was a week before that date, the actual date, he (A.H.) told me, “Your quit-smoking date is April 15. It’s coming up.” And I was like, “Wow, it’s coming up. It is . .” I had actually forgotten the date. He reminded me. The closer it got to that date, I started smoking even more, smoking even more. And I remember I said, “I’m going to go to church. And I’m going to pray on this.” And it was on Easter Sunday. I went to church. 1 remember telling the pastor, telling the other people, “I’m going to quit. It’s my last day smoking.” Actually, I really did not believe it. I was like, “Wow, why am I saying this? Because, you know you’re not going to quit.” But then that was my last day. It was my last day.

I got up the next morning, and _ I cried and I cried. It wasn’t a sad cry. It was a happy, joyous cry. I was crying, “I’m so happy.” And I was like, “‘Wow, what is wrong with me?’ And I just went about my day. I would see people smoking and I would say, “Wow.” I would look at them and I would just laugh, “Oh my God, what are they doing to themselves?’ And it was like I was living somewhere where I had never lived before, that next day. I just went on. I didn’t have any urges.

I was really excited. I felt good. I would actually say it was the best day of my life. As far as the way I felt, I was able to breathe, I could walk, not get tired. I could go up and down steps. I wasn’t huffing and puffing. It was, just like, a way that I had never felt before. I never felt that good before, that first day. I had just never felt that good.

After about 2 months, Zena ran into some difficulties. Within a short span of time, her daughter had a rash develop that required medical attention, her brother’s sister-in-law was hospitalized with severe heart failure, and the son of a childhood friend was killed.

So I felt that need to smoke. I felt that need to smoke . . I just felt like I needed that comfort, I just wished that comfort. But instead, what I did, was I talked to Arthur about it and then I started doing my meditation more times, more than just once a day. I would do it a couple times a day. And then I just kind of stopped everything that I was doing. I wouldn’t talk on the phone. I just would get to myself and deal with everything that was going on, to just kind of breathe it in. Breathe in what’s going on, breathe out what had to be done.

After 3 weeks, the urges subsided again. In her descriptions, Zena acknowledges having developed new tools, but also a new outlook on life. She describes that her old self:

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. would live by a calendar. Then it was, “What do I have to do on this day?” In the past I was living for tomorrow. OK tomorrow this, that. The meditation was to bring me into the present, to be mindful of what was going on with my body and to the world around me, to the people . . . I saw what I was missing as far as nature, the people, I was missing a lot. Just going through the motions. So now, I kind of live for that moment, in the moment. And to do what I can in that moment.

Zena discovered that what she could do with an orientation to moment-by-moment living was very powerful. It helped her to quit smoking.

Luther Pathway to cessation. Luther does not describe the experience of

precontemplation during his interview (in keeping with his action- oriented approach to life). Luther experienced the conflict of contempla- tion in relation to the declining health of his father.

I think I knew for quite a long time that I wanted to stop smoking. I knew continuing to smoke was a very bad thing for me. I had been doing it for a long, long time in considerable quantity. I had, you know, seen my father go through a horrible illness, partly as a result of smoking for a good part of his life. I was in a terribly embarrassing and awkward position of visiting my father while he’s dying in hospitals and running out for cigarettes, you know, to smoke. I just sort of assumed that there would be a point in time when it would coalesce for me and some inner voice would say, “It’s time to do this.”

Luther describes his preparation stage in the following way: “I felt motivated to do it in a way that I had never felt. And I wanted to act on it before it passed. It was going to pass. I knew that.”

During preparation he began to lay plans for his quit attempt.

I had a period of really just a few days when I talked to some people close to me about whether they have tried to do this, how I might go about it, should I do the patch, or get acupuncture, something else. What do people know about this? Then after engaging in all these conversations with a few people who were close to me, it occurred to me that probably I ought to come to a professional with some experience and that’s why I knocked on your door.

Luther was prescribed a nicotine patch as part of his program in the smoking cessation clinic.

For me, the patch was excellent. I mean it really was excellent. And I’m very glad I had that to help me with the physiological part . . . . But it became clear, if I stayed on the patch, if I put it on when I was supposed to, though we had a couple of episodes when I didn’t do this and it caused problems, it was clear that I could manage without the nicotine of cigarettes . . . if I could just withstand the first period of moving down to the new level of patch.

Luther was given control over the pace of the weaning of the patch, so

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that he believed that he had consolidated the effects of the withdrawal from each step.

I stayed on the high dosage of patch, and I liked that you were never dogmatic about how long you do that. And you said, “So you want to do this for another box? OK,” if I told you what was going on with me. And I certainly think that after not too long, I settled down back to an equilibrium.

While Luther used the nicotine patch, he also engaged other behavioral processes.

You got to try to substitute good stuff as much as you can . . . You do it initially at the time craving when it strikes you, then over the longer term, you just do it in your life more. And I’ve tried to do that with some middling success. I’m a sort of shleppy, overweight guy. I was concerned about my weight. Indeed, I did put on weight, and I was so assiduous about it, maybe I lost a couple of pounds. I started doing some exercise. Not a lot, but some. Maybe for the first time, quite a lot. And this feels very good.

He also became aware of rewards from not smoking.

The benefits of stopping are almost immediate in different ways. You feel a little better, you don’t cough in the morning, you got more money in your pocket. Especially these days, it’s a significant thing . . You don’t always have to be worried about cigarette supply. . . When you smoke, you’re always worried about, are you going to run out of cigarettes. And you’re always worried about, you’re going home after work and you look, and you have 5 cigarettes left. And you think to yourself, well, is 5 cigarettes gonna get me through until the morning? Probably not. So you got to go stop somewhere to get a pack of cigarettes. And you’re on your way home, you’re tired, you don’t want to go to some convenience store and give 5 dollars for a pack of cigarettes. The alternative is you say, “Well I’ll just do it later, I don’t feel like it.” Then inevitably, when you finish your 5 cigarettes at 10 or 11 o’clock at night, you think, “Well I can get through the night without cigarettes,” but you need one for the morning. So you have to drag yourself out and go to the gas station. So not having to contend with the logistics of smoking is a big benefit.

Luther describe an initial sense of euphoria over not smoking. He received lots of praise from others and was very pleased with his progress.

I think that sort of euphoria sort of carried me for a time, and then dissipated. And I think it sort of masked some of the real issues about stopping to smoke that were hard. . . “OK, well, you did it for 3 weeks, or you did it for a month, but now you’ve got to do it for the rest of your life.” It started hitting me. Everything’s so hard. I think in general, it’s true that the worse the rest of your life is, the harder it is. And I don’t know if there were things going on in my life that affected me then. My gut guess is that it was getting through the initial high and then settling down to the real difficulties of eventually doing this.

In this period, Luther increased his commitment. “I wanted it badly,” he says, “and now at that point I wanted also all the more because I have

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realized the benefits of- having succeeded for a short time. It was all the more reason to want it.”

This led Luther to continue to seek support from others, develop and apply his skillfulness to substitute new behaviors, and maintain an awareness of the benefits of cessation. After a while, Luther noticed a shift toward the maintenance phase of cessation. “It’s been 6 or 7 months,” he says. “I’m pretty sure, as much as one can know, but I’m pretty sure, as much as one can know these thing, I’m pretty sure I’m never gonna smoke again.”

Luther describes a healthful shift in his perspective on life that he attributes to quitting smoking.

But it seems to me that giving up smoking, stopping smoking, has made much of my sensory life more vivid than it was It seems to me that smoking must somehow be anesthetizing in some way and maybe that’s behavioral. Maybe you just insulate yourself more. Maybe there is something physiolog- ical about it. I’m so much more aware of the environment I’m in, the natural environment, the social environment . . . . This past spring and summer, I’ve been enjoying the spring and the summer much more than I have in quite a while.

So I feel very fortunate that this has worked well and I really see it as being a piece of doing more positive stuff or maybe looking at the world more positively . . . It wouldn’t surprise me if the literature has some connection between smoking and depression. I’m sure there’s some of that. . I think there’s also smoking as part of this persona that I think has a lot more cynicism attached. I mean I’m a cynical guy. Giving it up has just helped me open up to a lot of other things, other ways to fix my life, put things around me. I just couldn’t be happier.

Epilogue Recently, I (D.G.) had an extended discussion with a seasoned col-

league about physician-delivered smoking cessation. Early on in our discussion he stated, “This is a big piece of what I should be doing and I don’t feel like I am able to do it.” It was clear that he was very committed to this work. Much like smokers who are poised to quit, it struck me that he had an expectation of himself that had the effect of making him think he was inadequate.

We went on to discuss the science of the model and the importance of the building blocks of readiness, decisional balance, processes of change, and self-efficacy. We talked about the building blocks as doorways or points of inquiry into the life of the patient who smokes. We noted the role of the doctor with respect to smoking cessation; not to fix the smoker, but to facilitate the smoker’s development of his or her stage-appropriate skills. We discussed the fact that there is no best or right answer of how to handle a clinical scenario, and the importance of trusting the doctor-

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patient relationship to shape the professional coaching intervention; how physician work needs to be guided by physician introspection and commitment; and the principles of behavior change. We talked about the importance of having realistic expectations of change, of increas- ing quit rates in our primary care practices in the neighborhood of 5% to 15%.

After a stimulating hour of talk, we both were more settled. We became quiet, comfortable with our evolving expertise, and perhaps aware that our challenges lay not in the conference room where we sat, but in the examination rooms of the clinic. Then, on the way to the elevator, my colleague asked me, “So how do you teach this to other doctors?”

I answered, “When I walk into a room to give a talk, there are doctors in precontemplation, contemplation, preparation, and action with respect to their work with smoking cessation.”

My colleague then said, “So, to do this well, the doctors have to change.” “Yes.” We hope we have stimulated your curiosity, in some way, to think, or

feel, or act differently with respect to smoking cessation. We hope you are rewarded by your work.

Acknowledgment The authors wish to acknowledge the editorial assistance of Barbara Cohen.

We are grateful to our colleagues, Drs Irene Martinez, Richard Abrams, and Brendan Reilly, who read drafts of the manuscript and gave us helpful suggestions. We greatly appreciate the candor and time commitment of Daniel: Zena, Luther, and Susan for their interviews. We especially thank all those who have allowed us to coach them in their efforts to give up cigarettes in our clinical work. Their commitment has guided our continually developing understanding of smoking cessation. Finally, we wish to thank Dr James Prochaska for bringing his vision and scientific rigor to changing the behavior of smoking, and to acknowledge the enormous support he has given to our work at Cook County Hospital for the last 18 years.

References

1. Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of change. Homewood (IL): Dorsey Press; 1984.

2. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psycho1 1992;47: 1102-14.

3. Prochaska JO, Norcross JC, DiClemente CC. Changing for good. New York (NY): Avon Press; 1994.

4. Prochaska JO, Velicer WF. The transtheoretical model of behavior change. Am J Health Promot 1997;12:38-48.

5. Velicer WF, Prochaska JO, Fava JL, et al. Smoking cessation and stress

DM, July 2002 483

6.

I.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

management: applications of the transtheoretical model of behavior change. Ho- meostasis 1998;38:216-33. Prochaska JO, DiClemente CC, Velicer WF, et al. Standardized, individualized, interactive, and personalized self-help programs for smoking cessation. Health Psycho1 1993;12:399-405. Velicer WF, Prochaska JO, Fava JL, et al. Interactive versus noninteractive interventions and dose-response relationships for stage-matched smoking cessation programs in a managed care setting. Health Psycho1 1999;18:21-8. Velicer WF, Prochaska JO. An expert system intervention form smoking cessation. Patient Educ Counsel 1999;36:119-29. US Department of Health and Human Services. Treating tobacco use and depen- dence. Rockville (MD): US Department of Health and Human Services, Public Health Service; 2000. The Tobacco Use and Dependence Clinical Practice Guideline Panel Staff and Consortium Representative. A clinical practice guideline for treating tobacco use and dependence: a US Public Health Service report. JAMA 2000;283:3244-54. Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behaviors. New York (NY): The Guilford Press; 1991. Emmons KM, Rollnick S. Motivational interviewing in health care settings: opportunities and limitations. Am J Prev Med 2001;20:68-74. Rollnick S, Butler CC, Stott N. Helping smokers make decisions: the enhancement of brief interventions for general medical practice. Patient Educ Counsel 1997;31: 191-203. Valanis B, Lichtenstein E, Mullooly JP, et al. Maternal smoking cessation and relapse prevention during health care visits. Am J Prev Med 2001;20: l-8. Goldstein MG, DePue JD, Monroe AD, et al. A population-based survey of physician smoking cessation counseling practices. Prev Med 1998;27:720-9. Velicer WF, Fava JL, Prochaska JO, et al. Distribution of smokers by stage in three representative samples. Prev Med 1995;24:401-11. DiClemente CC, Prochaska JO, Fairhurst SK, et al. The processes of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psycho1 1991;59:295-304. Cancer Prevention Research Center, University of Rhode Island. Smoking: stage of change (short form). Available from http:Nwww.uri.edu/research/cprc/Measures/ Smoking1 1 .htm. Goldberg D, Hoffman A, Farinha M, et al. Physician delivery of smoking-cessation advice based on the stages-of-change model. Am J Prev Med 1994;10:267-74. Cancer Prevention Research Center, University of Rhode Island. Smoking: deci- sional balance (long form). Available from http://www.uri.edu/research/cprc/Mea- sures/Smoking07.htm. Cancer Prevention Research Center, University of Rhode Island. Smoking: deci- sional balance (short form). Available from http://www.uri.edu/research/cprc/Mea- sures/Smoking03,htm. US Department of Health and Human Services. The health benefits of smoking cessation: a report of the Surgeon General. Rockville (MD): US Department of Health and Human Services, Public Health Service; 1990. Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face stress, pain, and illness. New York (NY): Delta; 1990.

484 DM, July 2002

24. Cancer Prevention Research Center, University of Rhode Island. Smoking: process of change questionnaire (short form). Available from http://www.uri.edu/research/ cprc/Measures/SmokingOl .htm.

25. Samet JM. Health benefits of smoking cessation. Clin Chest Med 1991;12:669-79. 26. Remen RN. Kitchen table wisdom; stories that heal. New York (NY): Riverhead

Books; 1996.

DM, July 2002 485