The "Motivating Change" worksheet is designed for patient and physician use to help determine a patient's readiness to quit smoking. A printable copy can be provided to the patient, and the patient can complete the worksheet in the office with the physician or other heatlh care worker, or later on their own. They should be encouraged to ADD to this sheet as they find out more about their own motivations to quit smoking, and to keep it handy for encouragement.  

• Click here for a printable copy of the Motivating Change worksheet (WORD Document). (Or click here for the PDF file version.)

MOTIVATING CHANGE:

THE 5-R MODEL

For Tobacco Users Unwilling to Quit

• Relevance
  Encourage the patient to indicate why quitting is personally relevant, being as specific as possible. Motivational information has the greatest impact if it is relevant to a patient's disease status or risk, family or social situation (e.g., having children in the home), health concerns, age, gender, and other important patient characteristics (e.g., prior quitting experience, personal barriers to cessation).



• Risks
  The clinician should ask the patient to identify potential negative consequences of tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient. The clinician should emphasize that smoking low-tar/low-nicotine cigarettes or use of other forms of tobacco (e.g., smokeless tobacco, cigars, and pipes) will not eliminate these risks.
  
  Examples of risks are:
  • Acute risks: Shortness of breath, exacerbation of asthma, harm to pregnancy, impotence, infertility, and increased serum carbon monoxide.
  • Long-term risks: Heart attacks and strokes, lung and other cancers (larynx, oral cavity, pharynx, esophagus, pancreas, bladder, cervix), chronic obstructive pulmonary diseases (chronic bronchitis and emphysema), long-term disability, and need for extended care.
  • Environmental risks: Increased risk of lung cancer and heart disease in spouses; higher rates of smoking in children of tobacco users; increased risk for low birth weight, Sudden Infant Death Syndrome, asthma, middle ear disease, and respiratory infections in children of smokers.
  
  
• Rewards
  The clinician should ask the patient to identify potential benefits of stopping tobacco use. The clinician may suggest and highlight those that seem most relevant to the patient.
  
  Examples of rewards follow:
  • Improved health.
  • Food will taste better.
  • Improved sense of smell.
  • Save money.
  • Feel better about yourself.
  • Home, car, clothing, breath will smell better.
  • Can stop worrying about quitting.
  • Set a good example for children.
  • Have healthier babies and children.
  • Not worry about exposing others to smoke.
  • Feel better physically.
  • Perform better in physical activities.
  • Reduced wrinkling/aging of skin.
  
  
• Roadblocks
  The clinician should ask the patient to identify barriers or impediments to quitting and note elements of treatment (problemsolving, pharmacotherapy) that could address barriers.
  
  Typical barriers might include:
  
  • Withdrawal symptoms.
  • Fear of failure.
  • Weight gain.
  • Lack of support.
  • Depression.
  • Enjoyment of tobacco.
  
  

• Repetition
  The motivational intervention should be repeated every time an unmotivated patient visits the clinic setting. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.