Six-month–old Leah is admitted to the children’s ward with bronchiolitis. She requires supplemental oxygen and 24 hours of nasogastric feeds. Her family are familiar faces in the paediatric department as her brother Alfie has had two admissions this autumn already with viral-induced wheeze, and Leah was born at 30 weeks and spent five weeks in the SCBU. Leah’s mum is struggling as she is nine weeks pregnant again and has morning sickness. The nurses keep commenting on how often she “goes out for fresh air” and you notice on the ward round that she smells strongly of cigarettes.
There is a positive correlation between smoking and the severity of respiratory illnesses. The NICE 2021 guidelines specifically advise that parents/carers should be advised not to smoke in the baby’s or child’s home as it increases the severity of bronchiolitis. Smoking in pregnancy is associated with poorer outcomes including placental dysfunction, premature delivery, IUGR. Delivering smoking cessation advice is a core component of antenatal care. Sadly, many parents do continue to smoke, and many healthcare professionals feel uncomfortable tackling a difficult conversation or under-prepared for the reaction of parents who may feel that the healthcare professional is intruding into areas of personal choice and lifestyle.
After the morning ward round, where the consultant has assessed Leah and declared her medically fit for discharge, the consultant turns to you.
“Tell that mother she needs to stop smoking, it’s no good for her, it’s no good for Leah and no good for that baby she’s pregnant with. I can’t be doing with women like her endangering their baby’s lungs and filling up my ward with children who have no say in what they are breathing in.”
It is so easy to slip into the role of the enforcer/dictator telling people to change their behaviour and assuming a position of moral superiority. Of course, this doesn’t work! If it did, all our patients would eat well, exercise regularly, not take drugs and not smoke. Sadly, that’s not the reality we live in. Before we think about strategies for having this uncomfortable conversation with Leah’s mum, it is worth revising some behavioural psychology and remembering Prochaska and DiClemente’s Cycle of Change.
Leah’s mum is probably at the pre-contemplation stage. She may well not have any desire or drive to stop smoking. Even if she does want to stop it will not necessarily be easy to do so and relapses are common.
It is so tempting, as a healthcare professional, to tell someone what you think they need to do. This ignores their autonomy, makes assumptions that their priorities and yours are the same (often they won’t be) and risks the instant reflex response we all have when told to do something. Our inner child or chimp says “No, I won’t,” and metaphorically stamps its feet.
Motivational Interviewing (sometimes referred to as MI) is an approach to the consultation developed by Rollnick et al. The clinician encourages the individual to explore their fears and concerns about lifestyle change and gently nudges them to consider making different choices. MI encourages individuals to choose their own behaviours and lifestyle rather than being given a set of rules to abide by. There is strong evidence to show that individuals who engage with long term motivational interviewing counselling are more likely to refrain from smoking in the long run.
There are four general principles with motivational interviewing forming the acronym ‘RULE’.
RULE consists of:
- Resisting the urge to be didactic to alter someone’s behaviour.
- Understanding the individual and their reasons to alter the behaviour not the practitioner.
- Listening to the individual.
- Empowering the individual towards making a change.
You have heard of motivational interviewing. Having witnessed a disastrous encounter in clinic last week where your registrar told a parent to stop smoking, accused them of harming their child, made the parent cry and then got a complaint, you are quite motivated to try something else. Your colleague is a GP trainee and she tells you about Very Brief Advice (VBA) in smoking cessation. You take a short break from the ward and go online to do the NCST online VBA module and then go to speak with Leah’s mother.
Very Brief Advice
VBA is a tool used widely in primary care to engage smokers to think about quitting. Rather than challenging patients and potentially upsetting them, the method is designed to be a brief discussion. It can be used to start to nudge those in the pre-contemplation stage of the Cycle of Change towards contemplation then action. A 2020 study highlighted the positive effects of VBA stating that 25% of people who received VBA from the GP regarding smoking cessation were motivated to quit smoking.
You go into Leah’s room and speak to her mum about the discharge plan. You tell her you’ve noticed she goes out for “fresh air” often and ask if she smokes. Leah’s mum says she smokes 20 cigarettes a day but has tried to reduce a bit since being pregnant. She starts to be defensive about how hard it is to stop. You reassure her that you are not here to judge her. You would like her to know that, if she were to want to stop smoking, support is available and that a combination of medication and specialist input would dramatically improve her chances of success. Much to your surprise, Leah’s mum says she’d like to know more, and you give her a brief overview of the available local services and some of the prescription options available then provide her with details of the local stop smoking service.
Options for smoking cessation
There is strong evidence that a supported attempt at quitting is much more likely to result in cessation than simply “going cold turkey” on cigarettes. All areas of the UK have dedicated smoking cessation services which may be run on a self-referral or referral basis, with priority access for pregnant smokers who want to quit. Counsellors will support a smoker to set a quit date and support them through the process of stopping smoking. For the majority of patients, Nicotine Replacement Therapy in the form of patches, gums, lozenges or sprays are used, titrating down the dose at intervals with support. Bupropion is a Serotonin and Norepinephrine Reuptake Inhibitor (SNRI) which works effectively to block receptors and dramatically reduce cravings for cigarettes. It is not suitable for use in pregnancy. Patients often ask about vaping rather than smoking cigarettes – work is ongoing in terms of advice and evidence for whether vaping is a viable method of stopping smoking. It is not recommended in pregnancy.
Six months later you are walking through the local park when you see Leah’s mum pushing Leah and a new baby in a double buggy with Alfie running behind them. Leah’s mum smiles at you and beckons you over. She proudly shows you her new baby, Lily, who is a week old and shyly thanks you for looking after Leah and for changing her life. She tells you that you were the first person to raise smoking with her in a way that made sense, without “preaching” at her and without making her feel bad. After Leah was discharged from the hospital, she contacted the local smoking cessation service and with the help of Nicotine Replacement Therapy has been cigarette free for four months.
Lindson, L. et al. (2019) Motivational interviewing for smoking cessation. doi/10.1002/14651858.CD006936.pub4/full
Miller, W.R. & Rollnick, S. (2013) Motivational Interviewing: Helping people to change (3rd Edition). Guilford Press
National Centre for Smoking Cessation and Training (2014). Very Brief Advice training module. Available at: https://www.ncsct.co.uk/publication_very-brief-advice.php (Accessed October 2021).
NHS (2018) NHS stop smoking services help you quit. Available at: https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/ (Accessed October 2021).
Papadakis, S., Anastasaki, M., Papadakaki, M. et al. ‘Very brief advice’ (VBA) on smoking in family practice: a qualitative evaluation of the tobacco user’s perspective. BMC Fam Pract 21, 121 (2020). https://doi.org/10.1186/s12875-020-01195-w
Percival, J. (2012) Very brief advice can be used for smokers who want to quit. Available at: https://www.guidelinesinpractice.co.uk/smoking-cessation/very-brief-advice-can-be-used-for-smokers-who-want-to-quit/335442.article (Accessed October 2021).