1. Fax to Assist On-line Training for Certification Sponsored by Maryland Department of Health and Mental Hygiene and University of Maryland Baltimore County Module Three: The Stages of Change Motivational Strategies The 5 R’s for those Unready to Quit

2. Overview of Module 3 In this module you will learn about: –Stages of Change –Motivational Strategies –The 5 R’s

3. Stages of Change The process of quitting smoking can be conceptualized as progressing through a series of stages of change. Once individuals become dependent on nicotine, they seem to move and recycle through five stages on their way to achieving long-term abstinence from smoking. Each of the stages represents important tasks that the smokers need to accomplish in order to successfully change.

4. Stage of Change for Smoking Cessation 5 Stages of Change for Smoking Cessation: Precontemplation = Not ready for change Contemplation = Thinking about change Preparation = Getting ready to make change Action = Making the Change Maintenance = Sustaining the Behavior Change Until Integrated into Lifestyle

5. Stage of Change Tasks Precontemplation Awareness, Concern, Hope, Confidence Contemplation Risk-Reward Analysis & Solid Decision to Change Preparation Commitment & Creating An Effective/Acceptable Plan Action Adequate Implementation and Revising of Plan Maintenance Integration of new behavior into Lifestyle

6. Stages and Smoking Cessation The stages help to understand the temporal and motivational dimensions of smoking cessation. The following figures offer a illustrative view of the entire process –Figure 1 shows the factors related to stage movement –Figure 2 helps you to understand that it is not a linear process, but for most smokers, a cyclical one.

7. Figure 1. Theoretical and practical considerations related to movement through the Stages of Change Motivation Decision-Making Self-efficacy/Temptation Precontemplation Contemplation Preparation Action Maintenance Personal Environmental Decisional Cognitive Behavioral Concerns Pressure BalanceExperiential Processes (Pros & Cons)Processes Recycling Relapse

8. Precontemplation Increase awareness of need to change Contemplation Motivate and increase confidence in ability to change Action Reaffirm commitment and follow-up Termination Figure 2. Stages of Change Model Relapse Assist in Coping Maintenance Encourage active problem-solving Preparation Negotiate a plan

9. Cyclical Model for Intervention Most smokers will recycle through multiple quit attempts and multiple interventions. However successful cessation occurs for large numbers of smokers over time. Keys to successful recycling –Persistent efforts –Repeated contacts –Helping the smoker take the next step –Bolster self-efficacy and motivation –Match strategy to patient stage of change

10. Helping Smokers in Early Stages of Change Motivating smokers who are not ready to quit is always a challenge. There are some new ways that have been developed to address smokers in Precontemplation, Contemplation, and Preparation Stages called Motivational Enhancement Strategies. The next slides will help you understand these strategies.

11. Motivational Strategies Motivational approaches focus on providing: –Appropriate empathy –Personalized feedback –Positive reinforcement Motivational strategies can: –Support self-efficacy –Promote autonomy –Be applied when clients are unready, unwilling, or unable to quit smoking.

12. Addressing Barriers to Quitting Motivational strategies can be effective even if a client does not want to quit –Reasons for not quitting include: Misinformation, negative aspects of quitting (e.g., withdrawal), and prior unsuccessful attempts –Motivational strategies can help clients make more informed choices, help overcome barriers to quitting, and have greater confidence about future quit attempts. The 5 R's represent topics that are useful to address when helping smokers who are unready to quit move toward cessation. The 5 R’s are: Relevance, Risks, Rewards, Roadblocks, and Repetition

13. 1. Relevance Provide information that is relevant to the client’s situation, environment, and individual needs (e.g., health status, culture, and gender). When providing individualized information, ask the client to identify how quitting is relevant to them and their loved ones. Encourage the client to be as specific as possible.

14. 2. Risks Ask the client to identify negative effects of tobacco use; help identify which consequences are most important for the client. Inform the client that smoking low-tar/low- nicotine cigarettes or using alternative forms of tobacco (e.g., smokeless tobacco or cigars) will not reduce potential consequences. Address acute, long-term, and environmental risks associated with smoking.

15. 3. Rewards Ask the client to identify the benefits of quitting tobacco use, highlighting those most relevant for that individual. Possible rewards include : –Better health for individual and individual’s family –Improved sense of smell and taste –Money saved –Improved self-esteem –Being a good role model to children and family

16. 4. Roadblocks Help the client identify any obstacles to quitting. Some common roadblocks are: –Symptoms of withdrawal –Weight gain –Friends or family who smoke –Being afraid of failure –Lack of support Discuss treatment options (e.g., pharmacotherapy and problem-solving) to help overcome roadblocks.

17. 5: Repetition Every time you have contact with a client who is smoking, you can address the 5 R’s. It can be reassuring and motivating to share that many smokers will make several quit attempts before successfully quitting.

18. Summary of the 5 R’s Relevance –Help the client identify why quitting is relevant. Risks –Encourage the client to verbalize possible negative outcomes of tobacco use. Rewards –Have the client verbalize possible benefits of quitting tobacco use. Roadblocks –Work with the client to identify obstacles to quitting. Repetition –It may take more than one motivational intervention to help clients move toward a quit attempt.

19. Making an Impact on the Smoker Keys to success –Match interventions to the client’s stage of change For those less ready, i.e., in Precontemplation and Contemplation, address the 5 R’s. For those more ready, i.e. in Preparation help the client develop a quit plan. For those who have successfully quit, i.e. in Action or Maintenance, discuss how to prevent relapse. –Increase the pros of quitting and cons of continued smoking –Bolster self-efficacy and motivation to change

20. You have finished Module 3. Please proceed to Module 4, which covers what your client will experience once contacted by the Maryland Quitline.Module 4