Although tobacco use among adolescents and young adults has declined in recent years, data show that more than 3 million high school students and 600,000 middle school students still smoke cigarettes regularly. Motivational interviewing is one intervention that pediatricians can use to help their teenaged patients quit smoking before the onset of nicotine addiction and its accompanying comorbidities.
Tobacco use is a leading cause of morbidity and mortality for adults in the United States, but it is a disease of adolescence. Fifty-nine percent of new smokers in 2010 had their first cigarette before age 18 years.1 Among adult chronic smokers, 88% began by age 18 and 99% started before age 26.2 Because use typically begins during adolescence, consideration of this population is pivotal when developing and implementing intervention efforts.
US Department of Health and Human Services.2 GETTY IMAGES / PHOTODISC / KUTAY TANIRMuch progress has been made in reducing tobacco use among adolescents and young adults. The prevalence of daily cigarette smoking among US students in grades 9 through 12 decreased from 20% to 10.2% between 2001 and 2011.3 However, despite this decline, more than 600,000 middle school students and 3 million high school students regularly smoke cigarettes.2
Furthermore, adolescents frequently are not able to quit cigarette smoking once adopting the behavior. For every 3 young smokers, only 1 will quit during his or her lifetime.2 Older adolescents better understand the gravity of smoking than younger adolescents.4 However, the tragic ramification of this timing of understanding is that teenagers may already be addicted to nicotine before they internalize the risks.4,5 Therefore, we must motivate adolescents to quit smoking before the onset of addiction and its accompanying comorbidities.
A 2006 Cochrane Review of smoking-cessation programs for young people reviewed many types of interventions, including cognitive behavioral therapy (CBT), use of pharmacologic agents, stages of change with the transtheoretical model (TTM), and motivational interviewing (MI).6 Both TTM and MI were effective, whereas CBT and pharmacologic agents for adolescents did not have a statistically significant effect.
Motivational interviewing is defined as “a collaborative, goal-oriented style of communication with particular attention to the language of change . . . designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”7 This technique improves tobacco-use cessation when compared with brief advice or usual care.8
The efficacy of MI for smoking cessation in the adolescent population is an area of ongoing research. Individual prospective trials on the subject include the 2005 study by Hollis and colleagues, in which more than 2,500 adolescents were randomized to motivational tobacco-cessation intervention versus brief dietary advice.9 This study revealed significantly higher abstinence rates after 2 years in the MI group (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.03-1.47). Similarly, a 2006 study by Kelly and Lapworth highlighted short-term reductions in the quantity and frequency of smoking after an adolescent MI intervention for smoking cessation as compared with standard care.10 A 2010 systematic review of the efficacy of MI in adolescent and adult populations examined 31 smoking-cessation trials and showed a higher likelihood of smoking abstinence in the MI group than in the control group (OR, 1.45; 95% CI, 1.14-1.83).11
How can pediatricians apply this promising technique of MI in clinical practice? Any intervention in a busy office must be practical, applicable, and efficient in today’s time-conscious practice environment. Pediatricians can use TTM simply to help implement programs of behavior change.
The 4 core constructs of TTM are stages of change, processes of change, decisional balance, and self-efficacy (Table 1).12 Using these constructs, the health care provider can assist the adolescent on his or her path from tobacco use to smoking cessation. The goal is simply to assist the adolescent in moving forward from one stage of change to the next; for example, from precontemplation to contemplation or from preparation to action (Table 2).12
Effective use of MI helps move people forward through these stages of change. There are 5 main principles of MI: (1) expressing empathy through reflective listening; (2) developing a discrepancy between patients’ goals or values and their current behaviors; (3) avoiding argument and direct confrontation; (4) adjusting to patients’ resistance rather than opposing it directly; and (5) supporting self-efficacy and optimism (Table 3).13
This approach to smoking cessation is effective for adolescents because it focuses on avoiding confrontation and instead allows the individual to reach his or her own conclusions regarding the best way to approach behavior change. Teenagers often come to the clinic expecting a lecture about the harms and consequences of smoking, rather than a self-directed exploration of choices. They may give more credence to a provider’s encouragement about smoking cessation when they discover that the message is rooted in self-efficacy and in reconciling future goals with current behavior.
How might this process work in a clinical encounter? The following case-based example offers a scenario.
Part I: A 16-year-old male comes to the clinic for a routine basketball sports physical. Upon review of his psychosocial history, the boy reveals that he has smoked 5 cigarettes per day for the last year. He does not feel smoking is a problem for him and indicates that he does not want “another lecture about this.” He is not currently interested in cutting back.
According to the “stages of change” nomenclature, this young man is precontemplative; he has not even thought about cutting down or quitting his tobacco use. He has no intention to change his smoking behavior in the near future.
Using MI techniques, his pediatrician could take this opportunity to build rapport by expressing empathy through reflective listening. The practitioner aims to communicate to the patient that his view is valid and that he will not be judged for this. An example of effective reflective listening at this point could be, “So what I hear you saying is that you are tired of being lectured about your smoking. Tell me more about this.” The statement shows the teenager that his provider is listening to him and that the provider seeks to understand how he feels; this information may catch the teenager off guard because he is expecting a lecture.
This provides an opportunity to guide the teenager to “develop discrepancy,” which means helping the teenager discover the innate contradiction between his current behavior and his future goals. Sports-minded adolescents are unique because smoking may affect their athletic performance more noticeably than if they were sedentary. It is crucial to allow the teenager to develop his own reason for why smoking may interfere with his interests, rather than impose the concept on him. The pediatrician could go on to inquire, “What are your future basketball goals? How do you see smoking fitting in with these ambitions?” In the case of this patient, it is very likely that these first 2 principles are the only ones his pediatrician would address during the first office visit.
The entire motivational interview would take less than 5 minutes. The sports physical would conclude with a reiteration of the possible discrepancy offered by the patient, a simple statement from the pediatrician such as “The single best thing you can do for your health is to quit smoking and I am here to help," and an invitation or suggestion to return for follow-up in a few weeks to revisit the topic after the young man has had some time to reflect.
Part II: The young man returns to your office 6 weeks later. He presents after a week of coughing and nasal congestion, which has been interfering with his current basketball performance. In the middle of the visit, he mentions that he has been thinking about maybe cutting down on his cigarette smoking, but he starts identifying many reasons why this likely will not be successful.
The young man is now in the contemplative phase; he is both considering a healthful lifestyle change and simultaneously rejecting it. This is a great step forward along the stages of change and suggests that the previous MI visit was successful.
The next aspect of MI, “avoiding argumentation,” is especially important with the adolescent at this juncture. Arguments escalate the tension of the interaction, and once an argument begins, the content of the discussion is lost. Many teenagers are master arguers who enjoy the gamesmanship of the encounter, and the typical pediatrician, whose goal is to effect change, does not stand a chance of achieving this goal when going head to head against a teenager in a disagreement. For this reason, argument is incompatible with MI.
The main principle is less about what to say and more about the overall attitude behind the conversation. The goal is to use gentle persuasion instead of putting the patient on the defensive. If the conversation becomes argumentative, the pediatrician should attempt to terminate the argument and reassure the teenager that the provider cares for him, perhaps with a simple statement reiterating that the single best thing the teenager can do for his health is to quit smoking and that the provider is available to assist when the teenager is ready.
The fourth main principle of MI, “rolling with resistance,” is not to be confused with condoning adolescent tobacco use or assuming an overall stance of passivity. Rather, the physician helps the teenager to generate his own solutions. For instance, this young man may explain that he will feel pressured to smoke when he is around his friends, or that he has tried to quit in the past but failed, so why would this time be any different? Using the techniques of MI, the practitioner can reframe the question and put it back on the patient, allowing him to come up with his own solutions. For instance, one could say, “It sounds like you have thought of a lot of possible stumbling blocks to cutting back. What could possibly be some solutions?” This statement allows the teenager to feel empowered to identify workarounds for his dilemmas. In so doing, the teenager begins working through the preparation stage of change. If the teenager has no solutions to propose, the provider may offer suggestions for the patient to consider. If none seem to resonate with the patient, the provider may suggest they revisit the topic at a later time.
Finally, the fifth principle, “supporting self-efficacy,” comes into play. The pediatrician has an excellent opportunity to reinforce the young man’s confidence in his own ability to change. This sense of confidence is a strong predictor of successful behavior change. Teenagers show an increase in self-efficacy when they have both support and effective strategies to assist in quitting smoking, such as concrete plans for changing behavior, avoiding triggers, and setting a quit date. The pediatrician may say, “I am really impressed with your consideration of cutting back on your cigarette use and your plan to avoid your smoking friends after practice to eliminate those 2 cigarettes in your day, and I want you to know that I believe you can do it. Let’s plan to meet back in a month to see how things are going.” This brief message of belief in the patient’s ability to succeed, along with reinforcement of a specific strategy to assist the teenager with cutting down use, does not take long to provide, but may pay dividends in supporting the patient’s self-esteem on the difficult path ahead.
Part III: The patient returns to the clinic 1 month later. He informs you proudly that he has managed to cut down to only 1 to 2 cigarettes per day and he is now ready to quit completely.
At this point, it is important to guide the patient to choose a concrete quit date. He has taken action to cut down on his tobacco use during the past month and is preparing to quit entirely. It is essential to commend the young man on the huge strides he has already taken and to counsel him about the potential challenges that lie ahead. Stumbling blocks may include peers who continue to smoke, brief relapses, and chemical cravings. Anticipating these challenges, and identifying plans of action for these obstacles in advance, will allow a smoother transition to the action stage as well as progression to the maintenance stage. The pediatrician should encourage the teenager to schedule a follow-up clinic appointment at the time of the quit date to encourage ongoing progress and facilitate brainstorming of the best way to deal with obstacles.
Motivational interviewing is a promising area of focus for primary care practitioners who treat adolescent smokers. Through gradual, brief incorporation of these 5 main principlesâexpressing empathy, developing discrepancy, avoiding argumentation, rolling with resistance, and supporting self-efficacyâinto daily clinical practice, we assist adolescents’ movement along the stages of change on the path toward smoking cessation. Our nation is moving in the right direction regarding adolescent tobacco use, and we, as pediatricians, can keep the momentum going.
1. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011. Available at: http://www.samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm. Accessed September 11, 2013.
2. US Department of Health and Human Services. Preventing Tobacco Use Among Youth and Young Adults: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2012. Available at: http://www.surgeongeneral.gov/library/reports/preventing-youth-tobacco-use/full-report.pdf. Accessed September 11, 2013.
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12. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In: Glanz K, Rimer BK, Viswanath K, eds. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008:97-121.
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DR MYHRE is an adolescent medicine fellow at San Antonio Military Medical Center, Joint Base San Antonio, Texas. DR ADELMAN is Deputy Commander for Clinical Services at Kirk US Army Health Clinic, Aberdeen Proving Ground, Maryland, and associate professor of pediatrics, Uniformed Services University of the Health Sciences, Bethesda, Maryland. The authors have nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article. The opinions expressed herein are those of the authors and do not represent the official policy or position of the US Army, Department of Defense, or the US Government.
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