Randomizing smokers for standard treatment (ST) versus ST adding MI to the treatment protocol

1. Randomizing smokers for standard treatment (ST) versus ST adding MI to the treatment protocol A study at the Swedish tobacco quitline Asgeir R. Helgason & Lars Forsberg

2. Studies reviewed Celwyn Catley 2008 (Interlaken)

3. At the start of the project the counselors were randomly divided into two groups One of the groups was assigned to MI training: Two daystheoretical workshop (12 hours) followed by MITI based supervision (84 hours)

4. Throughout the study period the counselors in the “standard treatment” group received extra supervision, and training aimed to improve their skills as counselors, mainly based on behavior therapy techniques.

5. Randomization of patients The randomization of “patients” into two treatment protocols MI vs. ST, started when all MI counselors had achieved acceptable scores on EMPATHY and MI-spirit MITI-2 variables: Swedish MIC-Lab (Motivational Interviewing Coding Lab) Ca. 6 months

6. The counselor first in contact with the patient defined the patients treatment group

7. Follow-up Posted questionnaire 12-months after fist contact with the quitline.

8. Outcome measures Point prevalence abstinence = Not a single puff of smoke during the previous 7 days Continuous abstinence = Not a single puff of smoke during the previous 6 months

9. Results To date 592 smokers have responded to the 12-months follow-up questionnaire 350 were randomized into the standard treatment 242 were randomized into the MI treatment Differences in numbers between the groups are mainly due to the fact that two of the original MI counselors quit their job during the study period resulting in a reduced treatment capacity for the MI group.

10. Percentage smoke-free at the 12-monts follow-up

11. DEFINING FOUR GROUPS MI-based treatment MI 1 = MI adherent statements below 90% MI 2 = MI adherent statements 90% (or higher) Standard Treatment ST-1 = Scoring below group median on Empathy ST-2 = Scoring group median on Empathy ( = 4) * *Based on MITI-2 scoring = 1-7 scale

12. Percentage of smokers reporting abstinence at the 12-monts follow-up treated by four groups of counselors with different levels of MI skills Standard treatment Standard treatment MI MI MI:2 ST:2 MI:1 ST:1

13. The 90% cut-off 9 Juni 2008 Lisa Forsberg, Lars Forsberg & Asgeir R. Helgason

14. Methodological problems • At baseline all quitline counselors had basic knowledge of MI and had participated in a MI workshop. • Since the counselors were working in close proximity to each other, “spilling over” of MI competence to the standard treatment group was unavoidable. • MITI-monitoring of the standard treatment counselors showed that several of these counselors achieved relatively high scores on important MI variables like “empathy” and “MI-spirit”.

15. Methodological problems People calling the quitline are usually relatively motivated to quit

16. All these methodological problems are “conservative” and would be expected to diminish any positive effects of the MI treatment over the standard treatment

17. The “aero dynamics” of evocation :

19. Material and methods 1: * The treatment protocol at the Swedish quitline at base-line was a mixture of coaching, basic behavior therapy techniques (classical and operant), and pharmacological counseling. All patients were offered a chose between a “reactive treatment” (the patient initiates all contact with the quitline) or a “proactive treatment” ( the quitline counselors call the patient at appointed dates). • At baseline, all counselors ha basic knowledge of Motivational Interviewing and had attended a 1-2 day workshop in MI. • However, none of the counselors achieved an “acceptable score” on any of the MI variables measured with MITI-2 at baseline.

20. Material and methods 2: * At the start of the project the counselors were randomly divided into two groups. * Since most counselors worked part time and different number of hours, the groups were adjusted so that the counselors in both groups worked approximately the same number of hours at the start of the project. * One of the groups was then randomly assigned to a comprehensive training in Motivational Interviewing.

21. Material and methods 3: * The MI training started with a two day (12 hours) theoretical workshop with basic exercises conducted by an experienced MI trainer. * The first three months of training comprised four hours of group supervision every other week. Using audio taped treatment sessions and MITI-2 scoring. * After the initial training period, all MI counselors were instructed to continue to audio tape treatment sessions with six weeks interval. The instructions were to tape the first 3 sessions the counselor had during the appointed period. The tapes were coded at the coding laboratory. After the initial training period the MI counselors continued to receive four hour group supervision one per month based on the MITI coding and audio tapes for a period of the project. * The supervision continued throughout the recruitment and follow-up period of the study. The MI training started in February 2005 and finished in June 2007. A total of 84 hours of MITI based MI supervision. All MI education an training was conducted by psychologist/CBT-psychotherapist Dr. Lars Forsberg, an experienced MI trainer.

22. Patient inclusion and exclusion criteria • Approximately 20 % of all callers to the Swedish quitline are registered for treatment and defined as “patients”. • Patients registered during the period of 1st.September 2005 – 26 October 2006 (followed-up during 1st September 2006 – 26th October 2007), comprise the study base in the present study. To be registered as a “patient” the caller needs to meet the following criteria: 1) Express a need for support regarding tobacco cessation. 2) Be willing to confirm is/her identity by receiving a registration questionnaire and participate in a 12-month follow-up. Exclusion criteria for the study were: * Difficulties understanding Swedish. * Not meeting the criteria for becoming a patient. * Obvious mental impairment.

23. Specified Characteristics of MI Counsellor-client relationship: * Being collaborative * Client-centered * Nonjudgmental * Building trust * Expressing empathy The evocation tool-kit: * Reflective listening * Open questions * Exploring ambivalence * Exploring discrepancy Primary end-points: * Increasing self-efficacy * Increasing readiness * Increasing change talk * Reducing resistance Secondary end-points: * Behaviour change * Attitude change

24. The evocation tool-kit Exploring ambivalence: 1) Were are you on a scale of 0-10?; why are you not a 0?; and what do you need to be a 7? 2) Weighing pros vs. cons of a target behaviour Increasing discrepancy: Exploring core values and comparing behaviours with values (value cards?)e.g.you say that your family is the most important thing in your life, how does what you are doing affect your family? Open questions: Create space for growth Reflective listening: Simple vs. complex -> evokes empathy

25. The “aero dynamics” of evocation : Complex reflections The why not 0 ? - on the 0-10 scale

26. The “spirit” of MI COLLABORATION : the patient and the counsellor/doctor are working together to achieve a common goal and BOTH must agree on what that goal is AUTONOMY: The patient is in charge of the process. It is always the patient who knows best at each given point in time during the counselling process EVOCATION: If the counsellor wants to direct the patient towards a specific goal and/or insight, this needs to be evoked in the patient as opposed to inflicted or forced

27. Assessrisk factors and patient's willingness to change, usingopen &non -judgmentalquestions Listento what the patient wants &respectit ? Inform… Create the right growth climate for the patient's own desire to live a long and healthy life & use the harvest to fuel the change process. ….if patient wants to be informed

28. Present challenges * Quality control: When is MI being used & what does it take to educate counselors in MI? *Assessment modules: Further development of modules to assess the quality of MI (MITI and BECCI) *Coding laboratories:Training coders to score MITI and BECCI – between coders reliability * Randomized studies: Secondary end-points