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Motivational Interviewing and Smoking Cessation: Translating Research Into Practice with Fidelity

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Motivational Interviewing and Smoking Cessation: Translating Research Into Practice with Fidelity Open Access Journal of Family Medicine Special Article – Tobacco and Smoking Cessation Motivational Interviewing and Smoking Cessation: Translating Research into Practice with Fidelity Battaglia C1,2*, Peterson J1, Langner P1, Whitfield E1, Nandi A3, Benson SL4, Prochazka AV1,5 and Abstract 6 Cook PF Background: Motivational interviewing (MI) is an evidence based 1Department of Veterans Affairs, Eastern Colorado Health communication style effective for helping patients change their health behaviors Care System, USA such as smoking. We integrated an MI-based smoking cessation intervention 2University of Colorado Anschutz Medical Campus, into a home telehealth program for patients with Posttraumatic Stress Disorder Colorado School of Public Health, USA (PTSD). This study presents treatment fidelity data that can be of use when 3InStil Consulting, USA implementing an MI intervention for individuals with PTSD into clinical practice. 4Mental Health Partners, USA 5University of Colorado Anschutz Medical Campus, Method: We assessed and monitored the MI-based smoking cessation School of Medicine, USA intervention using a treatment fidelity framework which included five domains 6University of Colorado Anschutz Medical Campus, (study design, training, treatment delivery, patient receipt and enactment). College of Nursing, USA Results: Eighty-nine Veterans with PTSD who smoked were enrolled in the *Corresponding author: Battaglia C, Department of intervention arm of this study. Treatment fidelity was established by designing Veterans Affairs, Eastern Colorado Health Care System a study that mapped to a stage of change theory to deliver MI-based smoking 1055 Clermont Street, Research 151, Denver, CO 80220, cessation curricula via home telehealth plus weekly MI counseling calls. Initial USA and ongoing training by an MI expert ensured treatment delivery fidelity by nurse care managers. On average, participants received 12.25 calls lasting 16.7 Received: April 22, 2016; Accepted: May 26, 2016; minutes. They were satisfied with MI curricula (M= 9.1/11) and nurse counseling Published: May 30, 2016 (98.5%). A majority (73.1%) of participants stated they wanted to quit. There was a significant difference in stage of change between baseline call and the last call with higher levels of stage of change at the last call (p=<0.0001). Enactment measures revealed participants smoked nine fewer cigarettes over time (p=<0.0001). Conclusion: Implementing studies in health behavior change necessitates monitoring and demonstrating treatment fidelity. The results of this study can help guide translating smoking cessation research into practice in this hard to treat population. Keywords: Motivational interviewing; Smoking cessation; Treatment fidelity; Posttraumatic Stress Disorder; Veterans Abbreviations consumption, and various types of drug use. AARM: Avoid, Alarm, Replace, Mentally Cope; IQR: The evidence for MI as a smoking cessation intervention is Interquartile Range; M: Mean; MI: Motivational Interviewing; MIA- equally strong [3], although in one meta-analysis effect sizes for STEP: Motivational Interviewing Assessment: Supervisory Tools for smoking tobacco were only about half as large as those that have been Enhancing Proficiency; MINT: Motivational Interviewing Network of found for other types of behavior change [4]. One interpretation of Trainees; MITI; Motivational Interviewing Treatment Integrity; NIH this pattern of results is that smoking tobacco is a particularly difficult BCC: National Institutes of Health Behavioral Change Consortium; behavior to change [5]. Despite smaller effect sizes for smoking NRT: Nicotine Replacement Therapy; PTSD: Posttraumatic Stress cessation in some MI studies, tobacco smoking remains a leading Disorder; RCT: Randomized Control Trial; R:Q; Reflection to cause of mortality in the U. S. [6], and further intervention research is Question Ratio; SD: Standard Deviations; TTM: Transtheoretical therefore essential. MI works at least as well as any other intervention Model of Change; VA; Veterans Administration for this intractable problem and better than many [4], and can be delivered in a relatively brief amount of time compared to other well- Introduction studied patient counseling interventions [7]. Motivational interviewing (MI) is a patient-centered, strengths- MI is a good fit for Veterans with posttraumatic stress focused communication approach to help patients change problematic disorder (PTSD) who smokes because it is a non-confrontational behaviors [1], which is often used in clinical settings when the patient’s communication style [8]. Smoking rates are higher among Veterans behavior affects treatment outcomes [2]. In 30 randomized controlled seen in the Veterans’ Administration (VA) health care system than trials (RCTs) with over 9,000 total participants, MI has proven in the general U. S. population [9], and military service is a frequent efficacious for multiple difficult-to-change behaviors including diet time of smoking initiation for patients. Furthermore, Veterans with change, exercise, medication adherence, problem gambling, alcohol PTSD have smoking rates of 45% to 66% [10], and PTSD appears J Fam Med - Volume 3 Issue 3 - 2016 Citation: Battaglia C, Peterson J, Langner P, Whitfield E, Nandi A, Benson SL, et al. Motivational Interviewing and ISSN : 2380-0658 | www.austinpublishinggroup.com Smoking Cessation: Translating Research into Practice with Fidelity. J Fam Med. 2016; 3(3): 1059. Battaglia et al. © All rights are reserved Battaglia C Austin Publishing Group to be a risk factor for treatment failure, with lower success rates in The second and third domains of the treatment fidelity framework smoking cessation intervention among patients with PTSD compared are the most commonly reported in RCT research, focusing on to the general population [11,12]. Based on this combination of risk training and successful delivery of interventions by providers [19]. factors, helping Veterans with PTSD to quit smoking may be one of Researchers report the details of the training procedure, qualifications the most challenging applications of MI for health behavior change. of the trainers, amount of training, and follow-up supervision Identifying successes as well as failures of MI in this context therefore procedures, as well as behavioral measures of MI treatment delivery may inform the use of MI in other clinical settings where the same such as the Motivational Interviewing Assessment: Supervisory Tools type of barriers occur in less extreme forms. for Enhancing Proficiency (MIA-STEP) [23] or the Motivational Interviewing Treatment Integrity (MITI) [24]. Although a We previously pilot tested the feasibility and treatment fidelity of recent large-scale meta-analysis found no relationship between MI for smoking cessation in a telephone-and-technology-based MI provider training characteristics or behavioral MI implementation intervention to help this hard to treat population of Veterans with measures and MI treatment outcomes [3], information at these PTSD to reduce their tobacco use [13]. This small scale pilot study levels nevertheless provides important insights into the process of examined MI delivered by a single research nurse to a sample of 11 implementing MI in diverse practice settings. Veterans with PTSD. We then initiated a RCT to evaluate our MI- based smoking cessation intervention, which included a 90-session The last two domains of the framework may require adaptation smoking cessation curriculum integrated into a PTSD home telehealth for studies of motivational methods such as MI in which patients are care management program with 12 weeks of MI telephone counseling not necessarily expected to enact specific behaviors. Although the to determine if smoking behaviors improved. Outcomes of this study framework is clearly delineated for cognitive-behavioral interventions are discussed elsewhere [14]. For this study, we used data obtained that rely on knowledge transfer from providers to their patients [19], from the smoking cessation curricula and the weekly MI counseling the focus of MI is on helping patients to make decisions about their treatment to test the treatment fidelity of the intervention delivered health behaviors. In this context, studies have sometimes evaluated by two nurse care managers to Veterans with PTSD enrolled in the patient receipt and enactment of MI interventions via data on the intervention arm of RCT. number and type of intervention components actually completed – this is related to the number intended at the study design level, but The usual goal of treatment fidelity studies is to show that an focused on the actual receipt of interventions by participants rather intervention was delivered in a research study according to its original than what was originally designed. Patient satisfaction is another design; in other words, it is a manipulation check on the independent metric related to receipt of intervention, as in our pilot study [13]. variable of an RCT [15]. Training on MI [16] and behavioral rating Studies have also looked at patient-provided data on motivation or of counselors’ MI performance [17] are two elements of treatment readiness for change as evidence for enactment in MI [25]. In our fidelity. These factors are usually reported in MI research studies yet previous studies we included quit attempts as a measure of enactment they may or may not have any direct impact on treatment outcomes in smoking cessation [13,14]. [3]. Nevertheless, treatment fidelity
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