A 32-year-old woman comes to the office for follow-up of asthma. The patient reports that her asthma seems to be getting worse and describes increasingly frequent episodes of chest tightness and wheezing over the past several months. She says, "I find myself reaching for my inhaler more often than I used to, and I wonder if I should try a stronger medication." The patient has an 8-year history of intermittent asthma managed with an albuterol inhaler. She smoked marijuana in her 20s for several years and started smoking cigarettes over the past year. When asked about her tobacco use the patient says, "I'm smoking only half a pack a day or less and I really enjoy it, especially with my morning coffee." Which of the following is the most appropriate response to the patient?

Question

A 32-year-old woman comes to the office for follow-up of asthma.  The patient reports that her asthma seems to be getting worse and describes increasingly frequent episodes of chest tightness and wheezing over the past several months.  She says, "I find myself reaching for my inhaler more often than I used to, and I wonder if I should try a stronger medication."  The patient has an 8-year history of intermittent asthma managed with an albuterol inhaler.  She smoked marijuana in her 20s for several years and started smoking cigarettes over the past year.  When asked about her tobacco use the patient says, "I'm smoking only half a pack a day or less and I really enjoy it, especially with my morning coffee."  Which of the following is the most appropriate response to the patient?

Quizplus · Accepted Answer

This patient is concerned about her asthma and appears to be unaware that smoking is likely contributing to her worsening symptoms. Her perspective is that she enjoys smoking and that her habit of less than half a pack a day is not detrimental to her health. In patients who are either unaware of or appear to be minimizing the harms of smoking on their health, a helpful approach is the "elicit-provide-elicit" strategy. This involves a nonjudgmental, collaborative approach to exploring the patient's perspective, knowledge, and questions about the connection between smoking and their health; providing targeted information tailored to the patient (eg, this patient's asthma); and then eliciting the patient's understanding of the information provided. In this case, the patient's perspective is that she enjoys smoking and does not think it is harmful. The physician should offer to educate her about what usually happens to patients with asthma who smoke and to elicit her understanding of the information. This can be used as a starting point to help her develop ambivalence about continuing to smoke. Motivational interviewing techniques can then be used to further amplify the discrepancy between the patient's behavior and health goals. (Choice A) This statement fails to take a patient-centered, collaborative approach and has a judgmental tone that is critical of the patient's lack of knowledge. (Choice B) Suggesting that the patient should decrease her cigarette consumption before providing information about the harms of smoking is premature and unlikely to elicit change. (Choice C) Although this response provides needed information about the negative impact of smoking on asthma, it does not elicit the patient's understanding or promote her interest in the discussion. Positive change needs to be internally motivated; therefore, having a respectful, collaborative approach (eg, by asking the patient what she knows or would like to know rather than telling her) is preferable. (Choice D) Although this statement responds to the patient's interest in trying a stronger medication, it fails to address the underlying issue or educate the patient that addressing her smoking could relieve the worsening symptoms without the need for additional medication. Educational objective: Patients who are either unaware of or appear to be minimizing the harms of smoking can benefit from a nonjudgmental, collaborative approach. This involves asking for the patient's perspective, knowledge, and concerns about smoking; providing relevant information; and then eliciting the patient's understanding of the information. __________ References: Motivational interviewing for smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/25726920)

A 32-Year-Old Woman Comes to the Office for Follow-Up of Asthma