A 52-year-old man comes to the office for a routine follow-up appointment. The patient has a history of well-controlled hypertension and hyperlipidemia. He has a 35-pack-year smoking history and reports that he continues to smoke about 10-15 cigarettes daily. Family history is significant for lung cancer in his mother. His father died following a stroke at age 65. When asked about whether he has considered quitting, the patient replies that he is not ready to stop smoking. He says, "I know I probably should, but I'm just too stressed at work to give up my cigarettes right now. To be honest, I'm probably smoking closer to a pack a day." Which of the following is the most appropriate response to the patient?

Question

A 52-year-old man comes to the office for a routine follow-up appointment.  The patient has a history of well-controlled hypertension and hyperlipidemia.  He has a 35-pack-year smoking history and reports that he continues to smoke about 10-15 cigarettes daily.  Family history is significant for lung cancer in his mother.  His father died following a stroke at age 65.  When asked about whether he has considered quitting, the patient replies that he is not ready to stop smoking.  He says, "I know I probably should, but I'm just too stressed at work to give up my cigarettes right now.  To be honest, I'm probably smoking closer to a pack a day."  Which of the following is the most appropriate response to the patient?

Quizplus · Accepted Answer

11ec160b_368e_4f27_9249_7f85f5b485f5_MD0001_00 This patient has a family history of lung cancer and multiple risk factors for cardiovascular illness, including smoking, hypertension, hyperlipidemia, and family history of stroke. Although he states that he is not ready to quit smoking, he is ambivalent and aware that he probably should. An effective approach to patients who are not ready to quit is to explore their ambivalence (eg, worries about quitting vs not quitting), with the goal of enhancing the patient's internal motivation to make a change. Based on principles of motivational interviewing, the physician should acknowledge resistance to change and help the patient identify discrepancies between habits and long-term goals. Issues relevant to the patient's situation (eg, concern about his ability to manage work stress without smoking) and other possible barriers (eg, fear of nicotine withdrawal, failure, or gaining weight; enjoyment of tobacco) should be explored in a nonjudgmental way. Concerns about not quitting, such as fear of long-term health risks, can then be elicited to highlight ambivalence. Once the patient has identified the potential benefits and barriers to quitting, the physician can target these specific issues (eg, education, counseling, medication). (Choice A) This response redirects the conversation to the benefits of quitting and fails to acknowledge or explore the patient's resistance to change and his personal barriers to quitting. (Choice B) Although this statement acknowledges the patient's stress and conveys optimism about his ability to quit, it fails to address his ambivalent feelings, which may cause the patient to feel misunderstood and judged for his reluctance to quit. (Choice D) This response explores the patient's understanding of specific health risks of smoking but misses the opportunity to develop the patient's internal motivation to quit. (Choice E) The physician should first explore the patient's personal concerns and barriers to quitting before discussing smoking cessation treatment options. Educational objective: For patients who are not ready to quit smoking, it is helpful to explore their perspective about the pros and cons of continuing to smoke. Acknowledging resistance in a nonjudgmental manner while exploring ambivalence can help develop patients' internal motivation to change.

A 52-Year-Old Man Comes to the Office for a Routine