Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial

Enhancing medication management in hemodialysis patients: Exploring the impact of patient-centered pharmacist care and motivational interviewing

BACKGROUND

Patients on hemodialysis (HD) often uses several medications, making them highly susceptible to medication-related problems (MRP) thereby leading to medication nonadherence. Therefore, an innovative pharmaceutical care strategy incorporating drug therapy optimization (DTO) and motivational interviewing (MI) can mitigate medication-related problems and optimize patient care.

AIMS AND OBJECTIVE

The objective of this study is to assess the efficacy of pharmacist led interventions in utilizing DTO and MI techniques in managing medication related problems among patients undergoing hemodialysis.

METHOD AND DESIGN

A12-months, cross sectional prospective study was conducted among 63 End Stage Renal Disease (ESRD) patients on HD. DTO was conducted by the pharmacist to identify the MRP by reviewing complete medication list gathered from patient interview and medical records. All MRPs was classified using the PCNE classification version 9.00 and medication issues, that require patient involvement were categorized as patient-related, while those that necessitate physician intervention were classified as physician-related. The DTO was performed at the baseline, 6-month and at the final month of the study. Identified medication issues were communicated to the site nephrologist and was tracked during next follow up. Whereas MI was conducted physically at Month-3 and via telephone on month-6 and month-9 to address patient related medication issues.

RESULTS

Mean age of the study population was 48.5±14 years. While the mean number of prescribed medications was 8.1±2 with 57% of the patients taking more than 5 types of medication. After 12 months of pharmacist intervention using DTO and MI, a mean reduction in MRP was observed for both patient-related and physician-related MRPs across three time series. However, further analysis using repeated measure ANOVA revealed that the reduction in patient-related MRPs was statistically significant [F(1.491, 92.412) = 60.921, p < 0.05], while no statistically significant difference was detected in physician-related MRPs [F(2, 124) = 2.216, P = 0.113].

CONCLUSION

Pharmaceutical care service through DTO and MI can effectively reduce and prevent drug-related issues to optimize medication therapy among HD patients.

Let's Talk About Antibiotics: a randomised trial of two interventions to reduce antibiotic misuse

BACKGROUND

Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical.

OBJECTIVES

Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing.

DESIGN

Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019.

SETTING

Academic and private practice outpatient clinics.

PARTICIPANTS

Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached).

INTERVENTIONS

All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video.

MAIN OUTCOMES AND MEASURES

Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales).

RESULTS

Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) <2 years). Inappropriate antibiotic prescribing was similar among patients who consulted with a higher intensity (54/696, 7.8%) versus a lower intensity (85/904, 9.4%) clinician. A generalised linear mixed effect regression model (adjusted for the two-stage nested design, clinician type, clinic setting and clinician experience) revealed that the odds of receiving inappropriate antibiotic treatment did not significantly vary by group (AOR 0.99, 95% CI: 0.52 to 1.89, p=0.98). Secondary outcomes of revisits and adverse reactions did not vary between arms, and parent ratings of satisfaction with quality of parent-provider communication (5/5), shared decision making (9/10) and visit satisfaction (5/5) were similarly high in both arms.

CONCLUSIONS AND RELEVANCE

Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years.

TRIAL REGISTRATION NUMBER

NCT03037112.

Study protocol: Effectiveness of patient centered pharmacist care in improving medication adherence, clinical parameters and quality of life among hemodialysis patients

BACKGROUND

Patients requiring hemodialysis (HD) often have several chronic comorbidities, which necessitate the use of several medications and hence put them at high risk of polypharmacy. Medication-related problems (MRPs) among HD patients are a serious issue as they can increase morbidity and nonadherence with medications. To overcome this issue, a unique pharmacy practice model including medication review (MR) and motivational interviewing (MI) is needed to improve medication adherence, by reducing MRPs and optimizing therapeutic outcomes. The present study aims to assess the effectiveness of MR and MI in improving medication adherence, quality of life (QOL) and clinical outcomes among end-stage renal disease (ESRD) patients who are on dialysis.

METHOD AND DESIGN

This pre-post study will be conducted prospectively among patients with ESRD who have been on dialysis at the Hemodialysis Unit, Hospital Kuala Lumpur and the Hemodialysis Affiliated Centers of the University Malaya Medical Centre, from August 2020 till August 2021. Medication adherence will be assessed using the General Medication Adherence Scale (GMAS), whilst patients' HRQOL will be assessed using the Kidney Disease Quality of Life Short Form 36 (KDQOL-36). Clinical parameters such as blood glucose level, calcium, phosphate, hemoglobin and serum low-density lipoprotein (LDL) levels will be obtained from medical records. A total of 70 patients will be recruited.

DISCUSSION

We hypothesize that the implementation of pharmacy-based MR and MI may expect an increase in medication adherence scores and increase in HRQOL scores from baseline as well as achieving the clinical lab parameters within the desired range. This would indicate a need for a pharmacist to be involved in the multidisciplinary team to achieve a positive impact on medication adherence among hemodialysis patients.

TRIAL REGISTRATION

Ethical approval has been obtained from the National Medical Research and Ethics Committee NMRR: 20-1135-54435 and Medical Research Ethics Committee, University Malaya Medical Centre MREC ID NO: 202127-9811.

The Treatment Ambassador Program: A Highly Acceptable and Feasible Community-Based Peer Intervention for South Africans Living with HIV Who Delay or Discontinue Antiretroviral Therapy

We conducted a novel pilot randomized controlled trial of the Treatment Ambassador Program (TAP), an 8-session, peer-based, behavioral intervention for people with HIV (PWH) in South Africa not on antiretroviral therapy (ART). PWH (43 intervention, 41 controls) completed baseline, 3- and 6-month assessments. TAP was highly feasible (90% completion), with peer counselors demonstrating good intervention fidelity. Post-intervention interviews showed high acceptability of TAP and counselors, who supported autonomy, assisted with clinical navigation, and provided psychosocial support. Intention-to-treat analyses indicated increased ART initiation by 3 months in the intervention vs. control arm (12.2% [5/41] vs. 2.3% [1/43], Fisher exact p-value = 0.105; Cohen's h = 0.41). Among those previously on ART (off for > 6 months), 33.3% initiated ART by 3 months in the intervention vs. 14.3% in the control arm (Cohen's h = 0.45). Results suggest that TAP was highly acceptable and feasible among PWH not on ART.

Stress, Depression and Quit Attempt Outcomes among Unmotivated Smokers

INTRODUCTION

Stress and depressive symptoms have been linked to a reduced likelihood of sustaining smoking cessation. Because stress and depressive symptoms may negatively affect motivation to quit, stress and depression may also be important for whether or not smokers make a quit attempt.

OBJECTIVE

To examine the relationship between perceived stress and depressive symptoms and initiating a quit attempt in a smoking cessation induction trial.

METHODS

We conducted a secondary analysis of existing data from a randomized clinical trial (N = 255) comparing motivational interviewing to health education and brief advice for smoking cessation induction in smokers with low motivation to quit.

RESULTS

We observed positive associations between baseline predictors and quit attempts at week 12 (r = 0.192, p < 0.01 for depressive symptoms and r = 0.136, p < 0.05 for perceived stress). Logistic regression models revealed similar significant positive associations between baseline perceived stress and baseline depressive symptoms and making a quit attempt by week 12 (OR = 1.5, CI:1.03, 2.19 and OR = 1.03, 95% CI: 1.01, 1.06; respectively).

CONCLUSION

Unexpectedly, this study found generally small but consistently positive associations between baseline depressive symptoms and baseline perceived stress and making a quit attempt by week 12. The results can be viewed as encouraging in that interventions to encourage quit attempts do not appear counter-productive for individuals higher in stress and depressive symptoms, but these patients very likely will need additional supports to sustain abstinence.

Motivational Interviewing to Encourage Quit Attempts Among Smokers Not Ready to Quit: A Trial-Based Economic Analysis

INTRODUCTION

This study used data from a randomized controlled trial evaluating the efficacy of motivational interviewing (MI) relative to health education (HE) and brief advice (BA) to encourage quit attempts and cessation in order to determine their relative cost-effectiveness.

AIMS AND METHODS

Urban community residents (n = 255) with low desire to quit smoking were randomized to MI, HE, or BA which differed in communication style and/or number of treatment sessions. Incremental cost-effectiveness ratios were used to compare the intensive interventions (MI and HE) to BA for facilitating quit attempts and smoking cessation. Costs were calculated from the perspective of an agency that might engage in program delivery. Sensitivity analysis examined different assumptions for MI training and pharmacotherapy costs.

RESULTS

Total intervention delivery time costs per participant for MI, HE, and BA were $46.63, $42.87, and $2.4, respectively. Cost-effectiveness ratios per quit attempt at 24 weeks were $380 for MI, $272 for HE, and $209 for BA. The cost per additional quit attempt for MI and HE relative to BA was $508 and $301, respectively. The cost per additional quit for MI and HE relative to BA was $2030 and $752, respectively. Four separate sensitivity analyses conducted in our study did not change the conclusion the HE had a lower Incremental Cost-Effectiveness Ratio for both quit attempts and cessation.

CONCLUSIONS

HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable for smokers who are less motivated to quit. Providing valuable cost information in choosing different clinical methods for motivating smokers to quit.

IMPLICATIONS

All direct costs and activity-based time costs associated with delivering the intervention were analyzed from the perspective of an agency that may wish to replicate these strategies. A randomized controlled trial evaluating the efficacy of MI relative to HE and BA to encourage quit attempts and cessation determined their relative cost-effectiveness. HE was the most cost-effective of the three types of smoking cessation induction therapies and therefore may be preferable. Despite guideline recommendations, MI may not be the best approach to encourage quit attempts in diverse populations. Rather, a structured, intensive HE intervention might be the most cost-effective alternative.

Race moderates the effects of Motivational Interviewing on smoking cessation induction

OBJECTIVE

Health disparities necessitate exploration of how race moderates response to smoking cessation treatment. Data from a randomized clinical trial of Motivational Interviewing (MI) for smoking cessation induction were used to explore differential treatment response between African American (AA) vs Non-Black (NB) smokers.

METHODS

Adult tobacco smokers (138 AA vs 66 NB) with low desire to quit were randomly assigned to four sessions of MI or health education (HE). Outcomes (e.g., quit attempts) were assessed 3- and 6-months.

RESULTS

There was evidence of a Race by Treatment interaction such that MI was less effective than HE in AA smokers. Mean Cohen's d for the interaction effect was -0.32 (95% CI [-0.44, -0.20]). However, the race interaction could be accounted for by controlling for baseline relationship status and communication preference (wants directive approach).

CONCLUSIONS

MI may be less effective for smoking cessation induction in AA vs NB smokers when compared to another active and more directive therapy. The differential response between races may be explained by psychosocial variables.

PRACTICE IMPLICATIONS

MI may not be an ideal choice for all African American smokers. Patients' relationship status and preference for a directive counseling approach might explain disparities in response to MI treatment.

Parental Depression is Prospectively Associated With Lower Smoking Cessation Rates and Poor Child Asthma Outcomes

Background

Depressive symptoms are elevated in parents of asthmatic children compared with parents of healthy children. The role of depression in smoking cessation and pediatric asthma outcomes in this population is unclear.

Purpose

To prospectively examine the effect of parent depression on smoking cessation and child asthma outcomes.

Methods

Secondary analysis from a cessation induction trial involving Motivational Interviewing (MI) and biomarker feedback on secondhand smoke exposure (SHSe). Parents (n=341) had an asthmatic child (mean age=5.2 years) and did not have to want to quit smoking to enroll. Intervention included asthma education, MI, and SHSe feedback plus randomization to six counseling (MI; repeated feedback) or control calls (brief check on asthma) for 4 months. Depressive symptoms were defined as scoring ≥22 on the Center for Epidemiologic Study-Depression scale. Smoking outcomes were bioverified 7- and 30-day point-prevalence abstinence (ppa). Child asthma outcomes were past month functional limitation, health care utilization, and number of days with asthma symptoms. Data were obtained at baseline, 2, 4, and 6 months.

Results

Parental depression was associated with lower odds of abstinence (7-day ppa odds ratio [OR]=0.38, 95% confidence interval [CI]=0.23, 0.64; 30-day ppa OR=0.27, 95% CI=0.15, 0.47), greater odds of child health care utilization for asthma (OR=1.71, 95% CI=1.01, 2.92), and greater child asthma functional limitation (B=0.16, SE=0.06, p=.03) even after controlling for smoking status. Depression predicted a greater number of child asthma symptom days (B=1.08, SE=0.44, p=.01), but this became nonsignificant after controlling for smoking status.

Conclusions

Among parents who smoke, both depressive symptoms and smoking should be targeted for treatment aimed at improving pediatric asthma.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I² = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I² = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I² = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I² = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I² = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I² = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Effectiveness of motivational interviewing, health education and brief advice in a population of smokers who are not ready to quit

Background

Motivational Interviewing (MI), Brief Advice (BA) and Health Education (HE) are established smoking cessation induction methods for smokers with low desire to quit. Although randomized controlled trials (RCT’s) have been frequently used to assess these interventions the temporal efficacy and effectiveness of these interventions have been poorly elaborated. The present work endeavors to fill the gap by considering the full range of possible motivational outcomes for all of the participants.

Methods

As a two-step process, Markov Chain (MC) and Ordinary Differential Equation (ODE) models were successively employed to examine the temporal efficacy and effectiveness of these interventions by computing the gradual movements of participants from an initial stage of unmotivated smoker to stages of increased motivation to quit and cessation. Specifically, in our re-analysis of data from the RCT we examined the proportion of participants in 4 stages of readiness to quit (unmotivated, undecided, motivated, former smokers) over 6 months, across treatment groups [MI (n = 87), BA (n = 43) and HE (n = 91)].

Results

Although HE had greater efficacy compared to MI and BA (i.e., the highest smoking cessation rates), it had lower effectiveness at certain time points. This was due to the fact that HE had the greatest proportion of motivated smokers who quit smoking but simultaneously a large proportion of the motivated smokers became unmotivated to quit. The effectiveness of HE dropped substantially in weeks 3–12 and remained below the effectiveness of BA from week 12 onward. The 2-year ODE model projections show that the prevalence of motivated smokers in HE group may fall below 5%. The prevalence of HE former smokers can reach an equilibrium of 26%, where the prevalence of both BA and MI former smokers exceeds this equilibrium.

Conclusions

The methodology proposed in this paper strongly benefits from the capabilities of both MC and ODE modeling approaches, in the event of low observations over the time. Particularly, the temporal population sizes are first estimated by the MC model. Then they are used to parametrize the ODE model and predict future values. The methodology enabes us to determine and compare the temporal efficacy and effectiveness of smoking cessation interventions, yielding predictive and analytic insights related to temporal characteristics and capabilities of these interventions during the study period and beyond.

Trial registration

Testing Counseling Styles to Motivate Smokers to Quit, NCT01188018, (July 4, 2012). This study is registered at www.clinicaltrials.gov NCT01188018.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0511-0 contains supplementary material, which is available to authorized users.

Protocol for a randomised trial of higher versus lower intensity patient-provider communication interventions to reduce antibiotic misuse in two paediatric ambulatory clinics in the USA

INTRODUCTION

Children with acute respiratory tract infections (ARTIs) are prescribed up to 11.4 million unnecessary antibiotic prescriptions annually. Inadequate parent-provider communication is a chief contributor, yet efforts to reduce overprescribing have only indirectly targeted communication or been impractical. This paper describes our multisite, parallel group, cluster randomised trial comparing two feasible interventions for enhancing parent-provider communication on the rate of inappropriate antibiotic prescribing (primary outcome) and revisits, adverse drug reactions and parent-rated quality of shared decision-making, parent-provider communication and visit satisfaction (secondary outcomes).

METHODS/ANALYSIS

We will attempt to recruit all eligible paediatricians and nurse practitioners (currently 47) at an academic children's hospital and a private practice. Using a 1:1 randomisation, providers will be assigned to a higher intensity education and communication skills or lower intensity education-only intervention and trained accordingly. We will recruit 1600 eligible parent-child dyads. Parents of children ages 1-5 years who present with ARTI symptoms will be managed by providers trained in either the higher or lower intensity intervention. Before their consultation, all parents will complete a baseline survey and view a 90 s gain-framed antibiotic educational video. Parent-child dyads consulting with providers trained in the higher intensity intervention will, in addition, receive a gain-framed antibiotic educational brochure promoting cautious use of antibiotics and rate their interest in receiving an antibiotic which will be shared with their provider before the visit. All parents will complete a postconsultation survey and a 2-week follow-up phone survey. Due to the two-stage nested design (parents nested within providers and clinics), we will employ generalised linear mixed-effect regression models.

ETHICS/DISSEMINATION

Ethical approval was obtained from the Children's Mercy Hospital Pediatric Institutional Review Board (#16060466). Results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03037112; Pre-results.

Smokers who are unmotivated to quit and have a child with asthma are more likely to quit with intensive motivational interviewing and repeated biomarker feedback

OBJECTIVE

Smokers who are not motivated to quit are an important group for intervention, particularly if they have children with asthma. Research indicates that unmotivated smokers are less responsive to intensive interventions, although motivation-by-treatment interactions have not been tested. This study examines whether motivation to quit moderates the effect of a cessation induction intervention.

METHOD

Parents had an asthmatic child requiring urgent care, and did not have to want to quit smoking to be eligible for the study. Two home visits included asthma education, motivational interviewing (MI) for cessation, and feedback on child's secondhand smoke exposure (SHSe). Participants were then randomized (n = 339, 79.6% female) to receive Enhanced-PAM (Precaution Adoption Model; 6 MI calls including SHSe feedback) or PAM (6 contact control calls). Motivation to quit was assessed at baseline and point-prevalence abstinence (ppa) and SHSe outcomes were objectively measured.

RESULTS

At baseline, 38.9% were not motivated to quit. Those who were not motivated to quit were 3 to 4 times more likely to be abstinent at 6 months in Enhanced-PAM versus PAM (7-day ppa: OR = 3.71, 95% CI = [1.06, 12.99]; 30-day: OR = 4.15, 95% CI [1.20, 14.35]); those receiving Enhanced-PAM achieved quit rates comparable to motivated smokers. Those who were not motivated to quit were more than 4 times as likely to have very low/undetectable SHSe at follow-up in Enhanced-PAM versus PAM (OR = 4.46, 95% CI [1.31, 15.15]). Among motivated smokers, neither outcome significantly differed by treatment arm.

CONCLUSION

It cannot be assumed that smokers who are unmotivated to quit will not be responsive to intensive interventions. (PsycINFO Database Record

Executive function fails to predict smoking outcomes in a clinical trial to motivate smokers to quit

BACKGROUND

Executive function (EF) is considered an important mediator of health outcomes. It is hypothesized that those with better EF are more likely to succeed in turning their intentions into actual health behaviors. Prior studies indicate EF is associated with smoking cessation. Experimental and longitudinal studies, however, have yielded mixed results. Few studies have examined whether EF predicts post-treatment smoking behavior. Fewer still have done so prospectively in a large trial. We sought to determine if EF predicts quit attempts and cessation among community smokers in a large randomized trial evaluating the efficacy of motivational interventions for encouraging cessation.

METHODS

Participants (N=255) completed a baseline assessment that included a cognitive battery to assess EF (Oral Trail Making Test B, Stroop, Controlled Oral Word Association Test). Participants were then randomized to 4 sessions of Motivational Interviewing or Health Education or one session of Brief Advice to quit. Quit attempts and cessation were assessed at weeks 12 and 26.

RESULTS

In regression analyses, none of the EF measures were statistically significant predictors of quit attempts or cessation (all ps>0.20).

CONCLUSIONS

Our data did not support models of health behavior that emphasize EF as a mediator of health outcomes. Methodological shortcomings weaken the existing support for an association between EF and smoking behavior. We suggest methodological improvements that could help move this potentially important area of research forward.

Individual behavioural counselling for smoking cessation

BACKGROUND

Individual counselling from a smoking cessation specialist may help smokers to make a successful attempt to stop smoking.

OBJECTIVES

The review addresses the following hypotheses:1. Individual counselling is more effective than no treatment or brief advice in promoting smoking cessation.2. Individual counselling is more effective than self-help materials in promoting smoking cessation.3. A more intensive counselling intervention is more effective than a less intensive intervention.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies with counsel* in any field in May 2016.

SELECTION CRITERIA

Randomized or quasi-randomized trials with at least one treatment arm consisting of face-to-face individual counselling from a healthcare worker not involved in routine clinical care. The outcome was smoking cessation at follow-up at least six months after the start of counselling.

DATA COLLECTION AND ANALYSIS

Both authors extracted data in duplicate. We recorded characteristics of the intervention and the target population, method of randomization and completeness of follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically-validated rates where available. In analysis, we assumed that participants lost to follow-up continued to smoke. We expressed effects as a risk ratio (RR) for cessation. Where possible, we performed meta-analysis using a fixed-effect (Mantel-Haenszel) model. We assessed the quality of evidence within each study using the Cochrane 'Risk of bias' tool and the GRADE approach.

MAIN RESULTS

We identified 49 trials with around 19,000 participants. Thirty-three trials compared individual counselling to a minimal behavioural intervention. There was high-quality evidence that individual counselling was more effective than a minimal contact control (brief advice, usual care, or provision of self-help materials) when pharmacotherapy was not offered to any participants (RR 1.57, 95% confidence interval (CI) 1.40 to 1.77; 27 studies, 11,100 participants; I² = 50%). There was moderate-quality evidence (downgraded due to imprecision) of a benefit of counselling when all participants received pharmacotherapy (nicotine replacement therapy) (RR 1.24, 95% CI 1.01 to 1.51; 6 studies, 2662 participants; I² = 0%). There was moderate-quality evidence (downgraded due to imprecision) for a small benefit of more intensive counselling compared to brief counselling (RR 1.29, 95% CI 1.09 to 1.53; 11 studies, 2920 participants; I² = 48%). None of the five other trials that compared different counselling models of similar intensity detected significant differences.

AUTHORS' CONCLUSIONS

There is high-quality evidence that individually-delivered smoking cessation counselling can assist smokers to quit. There is moderate-quality evidence of a smaller relative benefit when counselling is used in addition to pharmacotherapy, and of more intensive counselling compared to a brief counselling intervention.

Cascade of Refusal-What Does It Mean for the Future of Treatment as Prevention in Sub-Saharan Africa?

Recent recommendations by the World Health Organization support treatment for all people living with HIV (PLWH) globally to be initiated at the point of testing. While there has been marked success in efforts to identify and expand treatment for PLWH throughout sub-Saharan Africa, the goal of universal treatment may prove challenging to achieve. The pre-ART phase of the care cascade from HIV testing to HIV treatment initiation includes several social and structural barriers. One such barrier is antiretroviral therapy (ART) treatment refusal, a phenomenon in which HIV-infected individuals choose not to start treatment upon learning their ART eligibility. Our goal is to provide further understanding of why treatment-eligible adults may choose to present for HIV testing but not initiate ART when indicated. In this article, we will discuss factors driving pre-ART loss and present a framework for understanding the impact of decision-making on early losses in the care cascade, with a focus on ART refusal.

‘I Sat Filling in This Form While Smoking and It Was Divine’. An Analysis of Free-Text Comments from Smokers Who Report They Have No Intention of Quitting in the Next Six Months

Introduction: Smokers unmotivated to quit are neglected by smoking cessation research. Free-text comment analysis is a potentially useful way to gain insight into this group's beliefs.

Aims: To analyse the free-text comments provided by smokers unmotivated to quit as part of a randomized controlled trial of computer-tailored feedback for smoking cessation.

Method: A random sample of 58,660 smokers were sent a smoking behaviour questionnaire (SBQ). The responses and follow-up outcomes of those providing free-text comments were compared to those who did not to assess the representativeness of the former group of smokers. The comments of participants unmotivated to quit (631) were thematically analysed.

Results: Those who provided a comment differed from those who did not on variables including education level and quit attempts at six-month follow-up. Emergent themes included; justification of smoking and restricting smoking instead of quitting.

Conclusions: The findings illustrate the value of free-text comments in identifying issues important to respondents. The identified themes highlight areas for future research in smokers unmotivated to quit including cutting down as a path to quitting and explicit messages regarding the inability of positive health behaviours to balance out the negative impact of smoking on health.

Trial registration: Current Controlled Trials ISRCTN05385712.

Recruiting unmotivated smokers into a smoking induction trial

Little is known about effective methods to recruit unmotivated smokers into cessation induction trials, the reasons unmotivated smokers agree to participate, and the impact of those reasons on study outcomes. A mixed-method approach was used to examine recruitment data from a randomized controlled cessation induction trial that enrolled 255 adult smokers with low motivation to quit. Over 15 months, 33% of smokers who inquired about the study were enrolled. Common recruitment methods included word-of-mouth, print advertisements and clinic referrals. Frequently mentioned reasons for participating included to: gain financial incentives (44.7%), learn about research or help others quit (43%), learn about smoking and risks (40%) and help with future quits (i.e. Quit Assistance, 23.9%). Separate regression models predicting study outcomes at 26 weeks indicated that smokers who said they participated for Quit Assistance reported higher motivation to quit (B 1.26) and were more likely to have made a quit attempt (OR 2.03) compared to those not mentioning this reason, when baseline characteristics were controlled. Understanding reasons for unmotivated smokers' interest in treatment can help practitioners and researchers design effective strategies to engage this population.

A Randomized Trial of Motivational Interviewing: Cessation Induction Among Smokers With Low Desire to Quit

INTRODUCTION

Despite limitations in evidence, the current Clinical Practice Guideline advocates Motivational Interviewing for smokers not ready to quit. This study evaluated the efficacy of Motivational Interviewing for inducing cessation-related behaviors among smokers with low motivation to quit.

DESIGN

Randomized clinical trial.

SETTING/PARTICIPANTS

Two-hundred fifty-five daily smokers reporting low desire to quit smoking were recruited from an urban community during 2010-2011 and randomly assigned to Motivational Interviewing, health education, or brief advice using a 2:2:1 allocation. Data were analyzed from 2012 to 2014.

INTERVENTION

Four sessions of Motivational Interviewing utilized a patient-centered communication style that explored patients' own reasons for change. Four sessions of health education provided education related to smoking cessation while excluding elements characteristic of Motivational Interviewing. A single session of brief advice consisted of brief, personalized advice to quit.

MAIN OUTCOMES MEASURES

Self-reported quit attempts; smoking abstinence (biochemically verified); use of cessation pharmacotherapies; motivation; and confidence to quit were assessed at baseline and 3- and 6-month follow-ups.

RESULTS

Unexpectedly, no significant differences emerged between groups in the proportion who made a quit attempt by 6-month follow-up (Motivational Interviewing, 52.0%; health education, 60.8%; brief advice, 45.1%; p=0.157). Health education had significantly higher biochemically verified abstinence rates at 6 months (7.8%) than brief advice (0.0%) (8% risk difference, 95% CI=3%, 13%, p=0.003), with the Motivational Interviewing group falling in between (2.9% abstinent, 3% risk difference, 95% CI=0%, 6%, p=0.079). Both Motivational Interviewing and health education groups showed greater increases in cessation medication use, motivation, and confidence to quit relative to brief advice (all p<0.05), and health education showed greater increases in motivation relative to Motivational Interviewing (Cohen's d=0.36, 95% CI=0.12, 0.60).

CONCLUSIONS

Although Motivational Interviewing was generally more efficacious than brief advice in inducing cessation behaviors, health education appeared the most efficacious. These results highlight the need to identify the contexts in which Motivational Interviewing may be most efficacious and question recommendations to use Motivational Interviewing rather than other less complex cessation induction interventions.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01188018.

Relationship of Autonomy Social Support to Quitting Motivation in Diverse Smokers

BACKGROUND

Research examining relationships between social support and smoking cessation has paid little attention to non-treatment seeking smokers and not considered the role of autonomy support for fostering quitting motivation. This study examined if autonomy support received from family and friends was associated with quitting motivation and making a quit attempt among diverse smokers with varying levels of quitting motivation. Demographic characteristics associated with autonomy support were explored.

METHODS

Participants (N=312) responded to advertisements seeking smokers "not quite ready to quit," and were primarily Black, low-income, and unemployed. Most (255) enrolled in a clinical trial of smoking cessation induction strategies (treatment sample). An additional 57 not meeting the trial eligibility criteria of low quitting motivation enrolled for baseline assessments only. Participants completed baseline measures of autonomy support received from friends and autonomous quitting motivation. In the treatment sample, quit attempts were assessed at 6-months follow-up.

RESULTS

Females reported higher levels than males of autonomy support from friends (p=0.003). Participants with a high school diploma/GED reported higher levels of support from family (p<0.001) and friends (p=0.014) than those with less education or a college/graduate degree. Both family (p=0.007) and friend (p=0.004) autonomy support scores were significantly, albeit weakly, associated with autonomous quitting motivation. Autonomy support was not associated with making a quit attempt.

CONCLUSIONS

Support from family and friends may promote autonomous reasons to quit among diverse smokers. Research is needed to assess the role of social support in the pre-quitting phases among racial and socio-economically diverse populations.

Exploring the Severity of Dependence Scale (SDS) as a possible measure of nicotine dependence

BACKGROUND

The time to first cigarette (TTFC) of the day is an emerging single-item indicator of nicotine dependence due to its robust associations with indices of physical dependence. However, it is unclear if this measure adequately captures other dimensions of dependence. The Severity of Dependence Scale (SDS) is a brief questionnaire used to assess psychological aspects of dependence that has not yet been extensively applied to smoking research.

METHODS

We examined associations between the SDS and TTFC among 255 smokers during the baseline session of a cessation trial. We also examined associations of the SDS and TTFC with biobehavioral dependence indices, quitting behaviors, and cognitive-affective variables and compared the relative contributions of both measures in predicting these variables.

RESULTS

TTFC was unrelated to SDS total score, but was related to individual SDS items. TTFC, but not SDS, was correlated with indices of physical dependence (e.g., cigarettes per day [CPD], carbon monoxide [CO]). Both TTFC and SDS were associated with quitting behaviors, with opposite directionality of associations. TTFC and SDS were both associated with cognitive-affective variables, but SDS outperformed TTFC in strength and number of these relationships. Including both the SDS and TTFC as regression model predictors often increased the amount of variance explained.

CONCLUSIONS

Findings suggest that SDS and TTFC assess different constructs of nicotine dependence; among smokers, the SDS appears to tap into nonphysical components of dependence (e.g., loss of control) that relate to quitting motivation and affect. Assessing nicotine dependence using only the SDS may fail to capture physical dependence and, further, may not reflect the same domains of addiction the SDS assesses in other drugs of abuse. Nonetheless, using 3 SDS items in addition to TTFC may offer utility over using TTFC alone.

Effects of a family-assisted smoking cessation intervention based on motivational interviewing among low-motivated smokers in China

OBJECTIVE

To test the efficacy of a family-assisted smoking cessation intervention based on Motivational interviewing (MI) among low-motivated Chinese smokers.

METHODS

A two-armed randomized controlled trial study design was utilized. 159 Smoker-supporter pairs were randomly allocated to the intervention (a family-assisted MI intervention-77) or control (an intensity-matched health education-82) group (IG & CG). Change in smoking characteristics, communication characteristics, Partner Intervention Questionnaire (PIQ), Decisional Balance Scale (DBL), and Situational Temptations Scale (STP) were measured at baseline, post-intervention, 3-month and 6-month follow-up.

RESULTS

Compared to CG, IG had more significant increase over time in self-report quitting attempts of at least 24h, biochemically verified 7-day smoking abstinence, the Positive dimension of PIQ and the Cons in DBL, whereas the daily cigarettes smoked, the Pros in DBL and STP were showed more significant decrease over time in IG (P<0.05). After intervention, the communication frequency and satisfactory were also improved by smokers (P<0.01).

CONCLUSION

The family-assisted MI intervention is more effective in changing the smoking behaviors and increasing the communication between smokers and family, than health education.

PRACTICAL IMPLICATIONS

Using the family-assisted smoking cessation intervention based on MI, community health service providers can influence and empower low-motivated smokers positively for quit smoking.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to quit smoking.

OBJECTIVES

To determine whether or not motivational interviewing (MI) promotes smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialized Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. Date of the most recent search: August 2014.

SELECTION CRITERIA

Randomized controlled trials in which motivational interviewing or its variants were offered to tobacco users to assist cessation.

DATA COLLECTION AND ANALYSIS

We extracted data in duplicate. The main outcome measure was abstinence from smoking after at least six months follow-up. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. We counted participants lost to follow-up as continuing smoking or relapsed. We performed meta-analysis using a fixed-effect Mantel-Haenszel model.

MAIN RESULTS

We identified 28 studies published between 1997 and 2014, involving over 16,000 participants. MI was conducted in one to six sessions, with the duration of each session ranging from 10 to 60 minutes. Interventions were delivered by primary care physicians, hospital clinicians, nurses or counsellors. Our meta-analysis of MI versus brief advice or usual care yielded a modest but significant increase in quitting (risk ratio (RR) 1.26; 95% confidence interval (CI) 1.16 to 1.36; 28 studies; N = 16,803). Subgroup analyses found that MI delivered by primary care physicians resulted in an RR of 3.49 (95% CI 1.53 to 7.94; 2 trials; N = 736). When delivered by counsellors the RR was smaller (1.25; 95% CI 1.15 to 1.63; 22 trials; N = 13,593) but MI still resulted in higher quit rates than brief advice or usual care. When we compared MI interventions conducted through shorter sessions (less than 20 minutes per session) to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651). Single-session treatments might increase the likelihood of quitting over multiple sessions, but both regimens produced positive outcomes. Evidence is unclear at present on the optimal number of follow-up calls.There was variation across the trials in treatment fidelity. All trials used some variant of motivational interviewing. Critical details in how it was modified for the particular study population, the training of therapists and the content of the counselling were sometimes lacking from trial reports.  

AUTHORS' CONCLUSIONS

Motivational interviewing may assist people to quit smoking. However, the results should be interpreted with caution, due to variations in study quality, treatment fidelity, between-study heterogeneity and the possibility of publication or selective reporting bias.

Motivational interviewing interactions and the primary health care challenges presented by smokers with low motivation to stop smoking: a conversation analysis

Background

Research indicates that one third of smokers have low motivation to stop smoking. The purpose of the study was to use Conversational Analysis to enhance understanding of the process in Motivational Interviewing sessions carried out by primary care doctors and nurses to motivate their patients to quit smoking. The present study is a substudy of the Systematic Intervention on Smoking Habits in Primary Health Care Project (Spanish acronym: ISTAPS).

Methods

Motivational interviewing sessions with a subset of nine participants (two interview sessions were conducted with two of the nine) in the ISTAPS study who were current smokers and scored fewer than 5 points on the Richmond test that measures motivation to quit smoking were videotaped and transcribed. A total of 11 interviews conducted by five primary health care professionals in Barcelona, Spain, were analysed. Qualitative Content Analysis was used to develop an analytical guide for coding transcriptions. Conversation Analysis allowed detailed study of the exchange of words during the interaction.

Results

Motivational Interviewing sessions had three phases: assessment, reflection on readiness to change, and summary. The interaction was constructed during an office visit, where interactional dilemmas arise and can be resolved in various ways. Some actions by professionals (use of reiterations, declarations, open-ended questions) helped to construct a framework of shared relationship; others inhibited this relationship (focusing on risks of smoking, clinging to the protocol, and prematurely emphasizing change). Some professionals tended to resolve interactional dilemmas (e.g., resistance) through a confrontational or directive style. Interactions that did not follow Motivational Interviewing principles predominated in seven of the interviews analysed.

Conclusions

Conversational analysis showed that the complexity of the intervention increases when a health professional encounters individuals with low motivation for change, and interactional dilemmas may occur that make it difficult to follow Motivational Interview principles. Incorporating different forms of expression during the Motivational Interviewing could help to build patient-centred health care relationships and, for patients with low motivation to stop smoking, offer an opportunity to reflect on tobacco use during the office visit. The study findings could be included in professional training to improve the quality of motivational interviewing.

Effectiveness of smoking cessation using motivational interviewing in patients consulting a pulmonologist

BACKGROUND

We aimed to investigate the role of the physician in practice and the factors that influence the success rate of smoking cessation.

METHODS

This study retrospectively analyzed 126 adult smokers who had visited the outpatient department of pulmonology, and received motivational interviewing with or without supplement drugs. The findings include continuous smoking abstinence rate, which was evaluated at 6, 12 and 24 weeks, and the factors associated with continuous abstinence for 6 months or longer.

RESULTS

The patients with only motivational interviewing accounted for 57.9%, while the nicotine patch therapy was applied to 30.2%; and varenicline was prescribed to 11.9%. The smoking cessation success rates of at 6, 12, and 24 weeks were 55.6%, 47.6%, and 33.3%, respectively. However, even in the failure group at six months, tobacco consumption was decreased under 10 cigarettes per day in 42.1% (53/126). In multivariate logistic regression analysis, degree of Fagerstöm Test for Nicotine Dependence (p=0.034; odds ratio, 3.607; 95% confidence interval [CI], 1.102-1.807), the absence of smoking-related lung disease (p=0.008; odds ratio, 4.693; 95% CI, 1.497-14.707), and education level (p=0.001; odds ratio, 181.420; 95% CI, 8.414-3,911.502) were the predictors of successful smoking cessation.

CONCLUSION

An improved continuous smoking abstinence rate can be obtained by motivational interviewing, regardless of the association with pharmacotherapy.