The 5 R's of Motivation

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Details how to increase a patient's motivation to quit using tobacco products.

For patients not willing to make an attempt at quitting, clinicians should provide a brief intervention to promote the motivation to quit. Motivation is also important for patients who do express interest in quitting. Ask patients to state their reasons for wanting to quit. Hearing their own answers helps strengthen their commitment, and you can provide positive reinforcement by supporting their reasons. Motivational interventions can be divided into 5 basic types, or the 5 R's: Relevance, Risks, Rewards, Roadblocks, and Repetition (Fiore et al. 2008).

Relevance	Ask the patient why quitting is personally relevant. The greatest impact is felt if reasons to quit are relevant to patient's family, social situation, health concerns, age, gender, or other patient characteristics.
Risks	Ask the patient to identify potential negative consequences of tobacco use. Highlight and suggest those most relevant to the patient. Acute Risks Shortness of breath Exacerbation of asthma Harm to pregnancy Impotency Infertility Increased serum carbon monoxide levels Long-Term Risks Myocardial infarction and strokes Lung and other cancers COPD Long-term disability and need for extended care Environmental Risks Increased risk of lung cancer and heart disease in partners Higher rates of smoking by children of tobacco users COPD Increased risk of low birth weight, SIDS, asthma, middle ear disease, and respiratory infections in children of smokers
Rewards	Ask the patient to identify potential benefits of quitting tobacco use. Suggest and highlight those that seem most relevant to the patient. Examples include the following: Improved health Improved sense of smell Save money Feel better about yourself Home, car, clothing, and breath will smell better Can stop worrying about quitting Set a good example for children Have healthier babies and children Eliminate children's exposure to smoke Feel better physically Perform better in physical activities Reduced wrinkling/aging of skin
Roadblocks	Ask the patient to identify barriers or impediments to quitting. Typical barriers might include the following: Withdrawal symptoms Fear of failure Weight gain Lack of support Depression Enjoyment of tobacco Partner or roommate smokes Address barriers in treatment (e.g., problem solving, pharmacotherapy).
Repetition	Repeat the motivational intervention every time the unmotivated patient visits the clinic. Tobacco users who have failed in previous quit attempts should be told that most people make repeated quit attempts before they are successful.

Motivation is also important in the maintenance stage. Congratulate ex-tobacco users on any success and encourage them to remain abstinent. Ask recent quitters open-ended questions to initiate patient problem solving (e.g., "How has quitting tobacco use helped you?"). Encourage the discussion of the following:

The benefits from cessation, including potential health benefits
Any success the patient has had in quitting
Problems encountered or anticipated threats to maintaining abstinence

Reference:

Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.

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