By Aviva Ariel-Donges
Tobacco use in rural areas is as American as backyard barbeques and Sunday night football. The American Lung Association reports that tobacco use is significantly more prevalent in rural communities than urban communities, with almost a third of residents in rural counties smoking (27.8% compared to 22.7% in urban areas). Moreover, smokeless tobacco use is higher in rural areas, rural users tend to start at an earlier age, and exposure to secondhand smoke is greater in rural households and workplaces. Despite higher rates of tobacco use and associated health problems (e.g., chronic lung disease, cancer, heart disease, stroke), residents of rural areas are less like to have access to evidence-based smoking cessation programs.
Smoking cessation efforts in rural communities require a multipronged approach. At the local level, city- and county-wide policies to establish tobacco-free settings promote new cultural norms regarding smoking and protect non-smokers from exposure to secondhand smoke. Marketing campaigns further increase residents’ knowledge of the harms of tobacco products and work to combat the long history of targeted advertisements in rural areas sponsored by tobacco companies. Finally, increasing the availability of smoking cessation programs through a variety of free Quit Your Way modalities (in-person, online, or telephone counseling plus nicotine replace products) aims to overcome the historically inadequate accessibility of such programs.
All healthcare providers should check in with patients about their smoking habits and provide an overview of the array of resources available to those who are open to quitting. Professionals at every level of the healthcare system have the ability to quickly assess patients’ smoking status, provide factual information on the harms of tobacco use, and help inspire patients to quit by employing a strategy called Motivational Interviewing.
Motivational Interviewing is a proven counseling style that helps ambivalent patients move toward quitting tobacco. Many healthcare professionals are accustomed to educating patients on what steps they need to take to improve their health, but research has shown that merely telling patients to quit smoking does not often result in behavior change. Motivational Interviewing, in contrast, aims to highlight discrepancies between the patient’s goals and their current behavior. Providers are encouraged to ask patients about their personal reasons for quitting, their understanding of the risks of tobacco use, the expected rewards of quitting, and any potential roadblocks to quitting. Healthcare providers can facilitate this type of productive conversation via four simple Motivational Interviewing techniques: Open-ended questions, affirmations, reflective listening, and summarizing.
By using open-ended questions that cannot be answered with a simple “yes” or “no,” providers embolden patients to engage in a dialogue. Through open-ended questions, providers can ask about patients’ interest in quitting (“What are you current thoughts about your tobacco use?”), concerns about quitting (“What do you think it would be like if you tried to quit smoking?”), and readiness for change (“How willing are you to quit smoking in the next month?”).
Affirmations remind patients that they are in control of their own choices and that they have their provider’s support. Positive statements of encouragement foster a compassionate relationship with patients who have likely felt judged by others for their tobacco use (“It sounds like you’ve been putting a lot of thought into the changes you want to make” or “Your commitment to your family is a strength that will help you when you choose to quit”). Pointing out patients’ small successes increases their self-confidence for continuing to move toward a tobacco-free life.
Listening carefully and reflecting back patients’ intentions shows that providers understand the challenges of being addicted to nicotine (“I hear you saying that cigarettes are how you cope when you’re stressed”). Targeted reflective statements can also be used to effectively highlight patients’ own words about their interest in and commitment to quitting (“It sounds like you want to quit smoking so you can breathe easier and chase your grandkids around the house”).
At the end of an appointment, summary statements can help hone in on patients’ current intentions (“Overall, it sounds like you’re interested in quitting, but you’re not sure you’re ready to commit to stopping right now”). Summarizing also allows providers to direct the conversation toward patients’ next steps (“What do you think about calling the Quit Line to hear more about their resources?” or “What would it be like if you started by cutting down on the number of cigarettes you smoke each day?”).
With repeated interactions, Motivational Interviewing techniques can establish a collaborative effort to enhance patients’ self-efficacy for quitting tobacco. For more information on how to effectively communicate with your patients about their intention to quit, visit https://srahec.org/distance-learning/ and take the free Motivational Interviewing online course.