Davis, Joan M

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Southern Illinois University CarbondaleOpenSIUCJournal Articles Department of Dental Hygiene2010Tobacco Cessation Counselling: MotivatingClients to QuitJoan M. DavisSouthern Illinois University Carbondale, davisdh@siu.eduFollow this and additional works at: http://opensiuc.lib.siu.edu/dh_articlesPublished in Canadian Journal of Dental Hygiene, Vol. 44 No. 5 (September/October 2010) athttp://www.cdha.ca/AM/Template.cfm?Section=The_Journal&Template=/CM/HTMLDisplay.cfm&ContentID=10383Editorial.This Article is brought to you for free and open access by the Department of Dental Hygiene at OpenSIUC. It has been accepted for inclusion inJournal Articles by an authorized administrator of OpenSIUC. For more information, please contact opensiuc@lib.siu.edu.Recommended CitationDavis, Joan M. "Tobacco Cessation Counselling: Motivating Clients to Quit." ( Jan 2010).196         2010; 44, no.5: 196–199tobacco cessation counselling: motivating clients to quit Joan m. davis, rdh, ms, ctts though much has been done to discourage tobacco use through education, programs, policy, and law, people continue to use this toxic substance with known carcino-gens—often leading to disease or even death.1 According to the Canadian Tobacco Use Monitoring Survey (CTUMS) 2009 half-year results,2 17% of Canadians 15 years or older (approximately 4.8 million) reported currently smoking. In the US, an estimated 20.2% (or 46 million) of Americans 18 years or older smoked.3 Overall, smoking prevalence has not changed from the previous year in either country. One could ask—why not? Tobacco use often leads to a chemical dependence and the establishment of behavioural patterns leading to an addiction or habit that can be very difficult to stop.4What we know about tobacco related oral health issuesOver the past sixty years, research has clearly dem-onstrated that the use of both smoked and, to a lesser degree, smokeless tobacco can lead to disabling disease or even death.1 Even those smoking 1–4 cigarettes a day, light smokers or “chippers” have been shown to have a significantly higher risk of dying from heart disease than non smokers.5 In addition, profound oral health risks are associated with smoked tobacco including oral cancer, pre-cancerous lesions6, periodontal disease7,8 increase in tooth loss, and implant failure6,9 Smokeless tobacco use, though not containing many of the 4,000 harmful chemicals found in tobacco smoke, can lead to precancerous lesions, dental caries and gingival recession.6In recent years researchers have explored the harm-ful oral effects of being exposed to passive smoking also called second hand or environmental smoke (ETS) on chil-dren. Erdemire et al.10 reported children exposed to ETS were found to have an elevated level of cotinine, a major metabolite of nicotine. Periodontally, these children had a lower clinical attachment level than children not exposed to tobacco smoke.10 Another study11 showed an increase in the incidence of dental caries to be significant in 5 year olds. Interestingly, “even after adjustment for parental edu-cational level, dietary and oral hygiene habits, a more than threefold elevated risk for caries associated with parental smok-ing was revealed in 5-year olds.”11p.255 Evidence is mounting that children are profoundly affected by exposure to ETS resulting in both general and oral health problems.Tobacco cessation counselling in dental hygieneAs oral health professionals committed to health pro-motion and disease prevention, it may be time to take a step back and explore the concept of tobacco cessa-tion counselling (TCC) and what it means. The often repeated US Public Health Service (PHS) Treating Tobacco Use and Dependence 2008 Update’s12 five As (Ask, Advise, Assess, Assist, Arrange) or brief intervention counselling13 (BIC—Ask, Advise, Assist, Arrange) are considered a brief editor ialintervention taking 3–5 minutes. A similar model is the Ask, Advise and Refer from the American Dental Hygiene Association where the tobacco using client is encouraged to quit then given “quit information”.14 At the heart of these models is to identify tobacco use then educate the client on the benefits of quitting. The PHS Guideline12 reports those who receive even a brief tobacco intervention have a significant increase in reaching and maintaining long term abstinence. The Guideline12 goes on to stress the likelihood of long term abstinence is even greater with counselling and medications. In 2004, Canadian Dental Hygienists Association published The Tobacco Use Cessation Services and the Role of the Dental Hygienist – CDHA position paper15p.1 where, among several recommendations, stated: “Dental hygienists can change clinical culture and clinical practice patterns so that every client who uses tobacco is identified and offered at least brief counselling”.The spirit of motivational interviewingWhile there may be many opinions as to what exactly entails effective tobacco cessation counselling, the inter-vention often involves more than imparting knowledge or education alone. Health education can be effective in motivating some to make a change in their health behav-iour, but in others, it may cause resistance resulting in the classic response “Yes, but…”. When asked, healthcare pro-viders often report client resistance as a barrier to offering tobacco use counselling. Could it be that at least some of the problem lies with the clinician rather than the client? Of PHS’s five As, the first three12—Asking, Advising and Assessing—could be offered in two ways. To illustrate the direct educational way:I see that you smoke. Your oral health is at risk and you really need to quit smoking in order to save your teeth.The second way would be supportive, empathetic:I see that you smoke, would it be OK if we talked a little more about it?Advice would follow after a collaborative dialogue has been started. Which method would elicit defensiveness, and which would make a client feel at ease?The theory of Motivational Interviewing (MI) has been extensively utilized in both clinical settings and research protocol. Psychologists first used this counselling tech-nique to treat alcoholism.16 MI has been advocated as an effective client centred tool for healthcare providers when associate Professordental hygiene, school of allied health college of applied science and artssouthern illinois university, carbondale, il 62902-6615davisdh@siu.edu 2010; 44, no.5: 196–199        197C e s s a t i o n  i n t e r v e n t i o ndental hygienist:  Did you realize you had this change of tissue in your mouth?(show with a mirror) Pause…listen… (creating awareness, inviting client’s involvement)Client: No! What causes that? client becomes involved and seeks more informationdental hygienist:  Well, this change in the cells is related to your smoking. I know you said you were not interested in quitting right now, but would you mind talking a little bit about it now? (asking permission) Pause…listen…Client:  Yeah! I don’t want to get cancer or anything. Is that what that is?continued client involvement, information seeking questions—client leadsdental hygienist:  The toxins in the tobacco smoke have altered the cells in your mouth and the white area, or leukoplakia, is considered precancerous.Pause…listen… (Providing targeted education without lecturing, righting)Client:  I had no idea! My uncle died of cancer and he suffered a lot.If I quit smoking, would that area go away?silence – give the client time to think, reflect client generated reflection moving closer to considering a behaviour changedental hygienist:  This type of leukoplakia can disappear over time if you stop smoking. Have you tried to quit in the past? exploring past quit attempts to understand better the struggles unique to the clientClient: Well, I quit for 6 months a few years ago… client continues to be involved, not resistant or defensive – the clinician is listening, non judgmental, resisting the urge to educatedental hygienist:  Tell me more about that. How were you able to succeed?supporting past quit attempts, learning from the experience, building on what the client says—empoweringClient:  Well, I used the patch, and it worked for a while but I went back to smoking. I suppose I could try that again…this is an example of change talk — use what the client has said to move the individual forward. the client needs to hear this rather than being told he or she needs to do itdental hygienist:  It is great to hear that you had success with the patch! That is certainly an option you could choose to quit.Can you tell me a little about what started you to smoke again?giving the client control over the quit plan, using the change talk support, empathy, reflection, exploring specific triggers for the clientthe simulation explores a conversation where tobacco smoke has compromised the health of the client, and oral pathology is present. the intent is to share how the “spirit” of mi may sound between a dental hygienist and a new dental client…as the intervention evolves, both the clinician and client are engaged. they build trust through acceptance, empathy, and support, leading the client to more disclosure. this conversation could encourage the client to agree to a quit plan, or it could end in the client expressing interest in quitting but not quite ready to do so. either way, a rapport is established which opens the way to further discussions at a later appointment.background:  41 year old female, smoker for 25 years, not interested in quittingoral pathology/Condition: abnormal leukoplakiaoral sign:  White thickening of the mucosa discovered during an oral cancer screenings a m p l e  m o t i v a t i o n a l  i n t e r v i e wdental hygienistClient198         2010; 44, no.5: 196–199treating behaviourally based chronic diseases,17–19 and encouraging good oral care.20Over thirty years of articles, books, and reports avail-able on MI indicate significant improvement in patients’ smoking behaviour.12,21–23 According to Miller and Rose,21 MI emphasizes two main components:1) a relational component where empathy and inter-personal elements are used, and2) a technical component where patients are encour-aged to share their thoughts, preferences and ambivalence, allowing the clinician to move the conversation in a posi-tive, health changing direction.Emmons and Miller19p.70 state, “Readiness to change is not a client trait but a fluctuating product of interpersonal inter-actions”, contending that clients do not stay in a static stage as described in the stages of change (precontempla-tion, contemplation, preparation, action maintenance).24 The active interaction of eliciting, reflection, examining discrepancies then resolving them may move a client from precontemplation to preparation stage in just a few minutes. At the heart of MI is establishing a rapport and building a relationship of trust between clinician and client where the client is in control of his or her own health. This is especially important between oral health providers and their clients who seek dental care on an annual or semi annual basis over many years. If a client perceives a clin-ician as judgmental, policing bad behaviour, or another tobacco lecture, the client may immediately disregard the advice, or even change providers.MI is considered a brief psychotherapy, and has num-erous aspects and skill sets to learn. Though some of the basic concepts are not difficult, MI takes time, self aware-ness, and practice to gain mastery. In response to the time collaborative Partnership between patient and clinician, dancing rather than wrestlingevocative elicit or bring out the patient’s own motivation and resources for changehonoring patient autonomyrecognize it is the patient who makes their own decisions – the power is in their hands, the clinician cannot change anyonetable 3. motivational interviewing resources.table 2. the four guiding Principles of motivational interviewing: rule.adapted from rollnick s, miller Wr, Butler cc. Motivational Interviewing in Healthcare: Helping Patients Change Behavior. 2008;8–10.table 1. the spirit of motivational interviewing.adapted from rollnick s, miller Wr, Butler cc. Motivational Interviewing in Healthcare: Helping Patients Change Behavior. 2008;6–7.motivational interviewing org. www.motivationalinterview.orgMotivational Interviewing in Healthcare: Helping Patients Change Behavior (2008) by s. rollnick, W. miller and c. Butler. new york: gilford Press. www.gilford.comMotivational Interviewing: Preparing People for Change (1991) by W. miller and s. rollnick. new york: guilford Press. www.gilford.comBuilding Motivational Interviewing Skills: A Practitioner Workbook (2009) by d. rosengren. new york: gilford Press. www.gilford.comr: resist the righting reflexresist the inner need to make things right, correct, often by educationu: understand your Patient’s motivationit is the patient’s own motivations (not ours) that are likely to trigger behaviour changel: listen to your Patientlisten at least as much as informing – often the answer lies within the patiente: empower your Patienthelp patients explore how they can make difference in their own healthconstraints involved in client care, brief adaptations of MI requiring from 5 to 30 minute interventions have been introduced.19 Rollnick et al.25 provide a practical approach to helping people change unhealthy behaviours without alienating them—within the time allotted for client care.25 The authors offer a rich array of concepts, frameworks, and vignettes that clinicians can learn and practise on their own.25 The “spirit” of MI is described as collaborative, evoca-tive and honoring of client autonomy (Table 1). The client is viewed as an equal partner in the individual’s health care, working out issues and making positive changes with the clinician acting as facilitator in the process. The guiding principles of MI are: resist, understand, listen, and empow-er (Table 2). Again, the clinician must relinquish the role of “authority and educator” and resist the urge to correct, or fix the “unmotivated or unknowledgeable” person.25 Rather, by taking the stance of listening and understand-ing the client’s motivation or reasons for change or not changing, the clinician can empower or give control back of the client.25 For example: You have five caries. You need to cut down on your sugar intake and brush your teeth more effectively. Or, I’m concerned that you have five caries this visit. Can you tell me about what you think may be happening here? (Pause, listen) The first is accurate but authoritative, in one direction and almost certain to evoke defensiveness or rebuttal. The second educates, shows empathy, and provides an opportunity for self reflection, assessment, and client empowerment to direct the discussion. For resources on health behaviour change, see Table 3.ConClusionHow can we be effective in helping our tobacco using clients quit? Addressing this behaviourally based chronic, relapsing disease from a client centred approach, clinicians can establish rapport and trust. This will empower and sup-port clients as they make positive health choices in both the short and long term. As clinicians, we have the abil-ity and opportunity to learn these proven techniques and skills that will help not only our tobacco cessation efforts, but all of our client interventions, breaking the cycle of chronic relapsing disease. 2010; 44, no.5: 196–199        199referenCes1. US Department of Health and Human Services, Centers for Disease Control and Prevention, US. Health consequences of smoking: a report of the Surgeon General. 2004.2. Health Canada. Canadian Tobacco Use Monitoring Survey 2010. [cited 2010 March 15]. Available from: http://www.hc-sc.gc/hc-ps/tobac-tabac/research-research/3. Cigarette smoking among adults and trends in smoking cessation. United States 2008. MMWR CDC Surveill Summ. 2009;58(44):1–8.4. Hatsukami DK, Stead LF, Gupta PC. Tobacco Addiction. Lancet. 2008;371:2027–385. Bjartveit K, Tverdal K. Health consequences of smoking 1–4 cigarettes per day. Tob Control. 2005;14:315–20.6. Warnakulasuriya S, Dietrich T, Bornstein MM, Peidro EC, Preshaw PM, Walter C, Wennstrom JL, Bergstrom J. Oral health risks of tobacco use and effects of cessation. Int Dent J. 2010;60:7–30. doi: 10.1922/IDJ_2532Warnakulasuriya247. Bergstrom J. Tobacco smoking and risk for periodontal disease. J Clin Periodont. 2003;30:107–13.8. Do LG, Roberts-Thomson KF, Sanders AF. Smoking-attribut-able periodontal disease in the Australian adult population. J Clin Periodontol. 2008;35:398–404.9. Schwartz-Arad D, Samet N, Samet N, Mamlider A. Smoking and Complications of Endosseous Dental Implants. J Periodon-tol. 2002;73:153–57.10. Erdemr EO, Sonmez IS, Oba AA, Bergstrom J. Perodontal health in children exposed to passive smoking. J Clin Periodon-tol. 2010;37:160–64.11. Leroy R, Hoppenbrouwers K, Jara A, Declerck D. Parental smoking behavior and caries experience in preschool children. Community Dent Oral Epidemiol. 2007;36:249–57.12. Fiore M, Jaen C, Baker T, et al. Treating tobacco use and dependence 2008 update. Clinical Practice Guideline. Rockville, MD: US Department of Health and Human Services. Public Health Service. May 2008.13. Brothwell DJ, Gelskey SC. Tobacco use cessation services pro-vided by dentists and dental hygienists in Manitoba: Part 1. Influence of practitioner demographics and psychosocial fac-tors. JCDA. 2009;74(10):905–905f.14. American Dental Hygienists’ Association. Tobacco Cessation Protocol for the Dental Hygienist Practice. Available from http://www.askadvisereferorg/downloads/Tobacco_Cessation_Protocol.pdf Accessed January 2010.15. Canadian Dental Hygienists Association. Tobacco Use Cessa-tion Services and the Role of the Dental Hygienist - a CDHA position paper. CJDH. 2004;38(6):1–20.16. Miller WR. Motivational Interviewing: Preparing People to Change Addictive Behavior. New York: Gilford Press. 1991.17. Miller NH. Motivational Interviewing as a prelude to coaching in healthcare settings. J Cardiovasc Nurs. 2010;25(3):247–51.18. Britt E, Hudson SM, Blampied NM. Motivational inter-viewing in health settings: a review. Patient Educ Couns. 2004;53(2):147–55.19. Emmons KM, Rollnick S. Motivational interviewing in health care settings: Opportunities and limitations. Am J Prev Med. 2001;20(1):68–74.20. Koerber A. Influencing patient behavior: education, com-pliance, & motivational interviewing. In: DI Mostofsky, AG Forgione, DB Giddon (eds). Behavioral Dentistry Ames, Iowa: Blackwell Publishing. 2006.21. Miller WR, Rose GS. Toward a theory of motivational inter-viewing. Am Psychol. 2009;64(6):527–37.22. Soria R, Almudena L, Escolano C, Yeste AL, Montoya J. A randomised controlled trial of motivational interviewing for smoking cessation. Br J Gen Pract. 2006;56:768–74.23. Lai DT, Cahill K, Quin Y, Tang J. Motivational interviewing for smoking cessation. Cochrane Database Syst Rev. 2010(1):Art. No.:CD006936.24. Prochaska JO, DiClemente CC. Stages and Processes of Self-Change of Smoking: Toward An Integrative Model of Change. J Consult Clin Psychol. 1983;51(3):390–95.25. Rollnick S, Miller WR, Butler CC. Motivational interviewing in health care: helping patients change behavior. New York: Guilford Press. 2008. ©CDHA

Tobacco Cessation Counselling: Motivating Clients to Quit

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Tobacco Cessation Counselling: Motivating Clients to Quit

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