Negotiating Behaviour through Motivational Interviewing to Help Smokers Quit

8th MADPHS Scientific Meeting & AGM 2017

AP. DR. WEE LEI HUM Health Behaviour and Smoking Cessation Specialist

Faculty of Health Sciences

Universiti Kebangsaan Malaysia

11th March, 2017

Teens Smoking

Characteristics Smoking is

temporary (Kenford et al., 2005)

Not considering themselves to be smokers (Berg et al., 2009)

87% who smoke daily continue

smoking throughout college

(Wetter et al., 2004)

Most do not smoke every day (50%

smoke occasionally) (Wetter et al., 2004)

Low motivation

to stop (Waters et al., 2006)

Infrequent use of cessation aids (Curry et al., 2007)

Kenford SL, Wetter DW, Welsch SK, Smith SS, Fiore MC, Baker TB. Progression of college-age cigarette samplers: what influences outcome. Addict Behav 2005;30:285–294. [PubMed: 15621399] Wetter DW, Kenford SL, Welsch SK, Smith SS, Fouladi RT, Fiore MC, Baker TB. Prevalence and predictors of transitions in smoking behavior among college students. Health Psychology 2004;23:168–177. [PubMed: 15008662] Berg CJ, Lust KA, Sanem JR, Kirch MA, Rudie M, Ehlinger E, Ahluwalia JS, An LC. Smoker selfidentification versus recent smoking among college students. Am J Prev Med 2009;36:333–336. [PubMed: 19201148] Waters K, Harris KJ, Hall S, Nazir N, Waigandt A. Characteristics of Social Smoking Among College Students. Journal of American College Health 2006;55:133–139. [PubMed: 17175899] Curry SJ, Sporer AK, Pugach O, Campbell RT, Emery S. Use of tobacco cessation treatments among young adult smokers: 2005 National Health Interview Survey. Am J Public Health 2007;97:1464– 1469. [PubMed: 17600243]

Nicotine use Magnitude of Teenage Smoking in Malaysia -

Where are we now?

2 in 10 boys

smoke; 2 in

100 girls

smoke (NHMS, 2015)

7 in 10 tried smoking before

the age of 14 years (NHMS, 2015)

4 in 10 teenage smokers had parents who smoked (NHMS, 2015)

4 in 10 teenage smokers exposed to secondhand smoke (NHMS, 2015)

9 in 10 teenage smokers tried to quit smoking (NHMS, 2015)

% of students smoked had increased double from Form 1 (6.8%) to Form 5 (15.7%) (GSHS, 2012)

Institute for Public Health (IPH). Report of the Global Adult Tobacco Survey (GATS) Malaysia, 2011, Ministry of Health Malaysia, 2012

Institute for Public Health (IPH). Report of the National Health Morbidity Survey (NHMS) Malaysia, 2015, Ministry of Health Malaysia, 2016

PREVALENCE CURRENT SMOKER 2015 AGE PERCENTAGE

15 – 19 12.9 (Secondary school/college)

20 – 24 24.7 (College/workforce)

25 – 29 26.0

30 – 34 27.3

35 – 39 28.1

40 – 44 25.5 (quitting/premature death)

Majority remain as a smoker……

Smoking Cessation Interventions in Schools

• Few cessation interventions have been evaluated (1)

and none have been disseminated widely

• Mixed Results (2)

• Lack sustainance (3)

1.Bader P, Travis HE, Skinner HA. Knowledge synthesis of smoking cessation among employed and unemployed young adults. Am J Public Health 2007;97:1434–1443. [PubMed: 17600254] 2. Thompson B, McLerran D, Livaudais JC, Coronado GD. A group-randomized tobacco trial among 30 Pacific Northwest colleges: results from the Campus Health Action on Tobacco study. Nicotine Tob Res 2010;12:635–646. [PubMed: 20447935] 3. An LC, Klatt C, Perry CL, Lein EB, Hennrikus DJ, Pallonen UE, Bliss RL, Lando HA, Farley DM, Ahluwalia JS, Ehlinger EP. The RealU online cessation intervention for college smokers: a randomized controlled trial. Prev Med 2008;47:194–199. [PubMed: 18565577]

Population-Based Approaches

• Health education to the public

• Cigarette pack warning

• Increase price tax

• No-smoking areas • 22% of Malaysians smoke despite these efforts

• Health education are insufficient to induce change, what can busy dentists do with limited time?

2 6

What is Motivational Interviewing?

4. Butler CC, Rollnick S, Cohen D, Bachmann M, Russell I, Stott N. Motivational consulting versus brief advice for smokers in general practice: A randomized trial. Br J Gen Pract 1999;49:611–616. 5. Borrelli B, Novak S, Hecht J, Emmons K, Papandonatos G, Abrams D. Home health care nurses as a new channel for smoking cessation treatment: outcomes from project CARES (Community-nurse Assisted Research and Education on Smoking). Prev Med 2005;41:815–821. [PubMed: 16182355] 6. Fiore, MC.; Jaen, CR.; Baker, TB., et al. Clinical Practice Guideline. Department of Health and Human Services. Rockville, MD: PH. Service; 2008. Treating Tobacco Use and Dependence: 2008 Update 7. Soria R, Legido A, Escolano C, Lopez Yeste A, Montoya J. A randomised controlled trial of motivational interviewing for smoking cessation. Br J Gen Pract 2006;56:768–774. [PubMed: 17007707]

7

• A brief psycho-therapeutic • Effective way of talking about change • MI has been found to increase smokers:-

• Readiness to quit (4) • Increase quit attempts (5)

• Reduce number of cigarettes smoke (5) • Enhance cessation (6) including among adolescents (7)

Core Clinical Dilemma • “I know it’s bad for me, but I enjoy smoking”

• How can we promote change in people who are unwilling or unmotivated?

2 8

Key Principles of Tobacco Cessation Strategies

• No Wrong Door

• Not Too Old Or Too Young

• No Failure

• Relapses as learning opportunities

2 9

FUNDAMENTALS OF MOTIVATIONAL INTERVIEWING

• Partnership

• Autonomy

• Compassion (keep the client’s best interest in mind)

• Evocation (best idea come from the client)

“People will not remember you for what you have done but for how they experienced you”

2 10

How the Intervention Might Work ?

• Motivation is a state of readiness to change, that may fluctuate over time, and can be influenced by the practitioner (8)

• Resolve client’s AMBIVALENCE - Procastination (9)

• Listening reflectively (8)

8.Miller WR, Rollnick S. Motivational interviewing: Preparing people for change, 2nd ed. New York: Guilford Press; 2002 9.Rollnick 1995 Rollnick SR,Miller WR.Whatismotivational interviewing? . Behavioural and Cognitive Psychotherapy 1995;23(4): 325–34.

11

What to Avoid?

• Confrontational style

• Assessing your client too early

• Not pushing for change prematurely

• Telling your client how to fix the problem

• Establing power

• Low motivation should not be thought of as a personality problem

8.Miller WR, Rollnick S. Motivational interviewing: Preparing people for change, 2nd ed. New York: Guilford Press; 2002. 12

Assessment Process

• Consists of an initial assessment, f/up 2 – 4 treatment sessions

• Initial assessment: a plan for change

• Next sessions : achieving the plan

• Applied both as a stand-alone intervention or with other treatments, and in arrange of settings (10)

10. Britt 2002 Britt E, Hudson SM, Blampied NM. Motivational Interviewing in health settings: a review. Patient Education and Counselling 2004;53(2):147–55. 13

5 PRINCIPLES OF MOTIVATIONAL INTERVIEWING

1. Avoid arguing 2. Express empathy 3. Develop discrepancy

4. Roll with resistance 5. Support self-efficacy

1. Avoid Arguing

• Emphasizing personal choice and control

• “Yes, it looks like you’re not ready to quit. What you do is entirely your choice”

2. Express Empathy

• Let the patient know that you understood him

• “So you’re feeling angry because your parents made you come here, and you’re not even convinced that your smoking is a problem”

3. Develop Discrepancy

• Gaps in patient’s behaviour and his personal values

• “So, on the one hand, you want to be a good son, but you also mention that you’re concerned about being bad good role model to your brother by smoking. How does that fit for you?”

4. Roll with Resistance

• Meet resistance with reflection

• “So you’re not so sure that you will consider stopping your smoking right now”

5. Support Self-efficacy

• Optimism that the student is capable of making the change

• “I have seen other students succeeded with this exact level of smoking”

Cochrane Systematic Reviews

Editorial Group: Cochrane Tobacco Addiction Group

Outcome: Abstinence at 6-months f/up. Lost to f/up as continuing smoking or relapsed

Selection criteria: RCTs in which motivational interviewing were offered to assist cessation

Objective: To determine wether or not motivational interviewing promotes cessation

Identified 28 studies published between 1997 and 2014, involving over 16,000 participants

MI interventions were compared to ‘usual care’ or brief advice (self-help manuals, booklets or videos)

Citation: Lindson-HawleyN,ThompsonTP, Begh R.Motivational interviewing for smoking cessation. CochraneDatabase of Systematic Reviews 2015, Issue 3. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub3.

The duration of sessions ranged from 10 - 60 minutes across studies

Most commonly-used approach - feedback intended to develop discrepancy between smoking and personal goals in a non-threatening manner (11)

RESULTS: Duration of Session

MI sessions lasted less than 20 mins produced a significant, larger effect (RR 1.69) (95% CI 1.34 to 2.12; 9 trials, N =

3651; I² = 27%; Analysis 1.3.1)

Longer than 20 mins produced a smaller effect (RR 1.20) (95% CI 1.08 to

1.32; 16 trials, N = 10,306; I² = 56%; Analysis 1.3.2)

Number of Sessions

Single session (RR1.26) (95% CI 1.15 to

1.40; 16 trials, N = 12,103; I² = 43%; Analysis 1.4.1)

Similar effect size to multiple sessions (RR1.20) (95% CI 1.02 to 1.42; 11 trials, N =

3928; I² = 56%; Analysis 1.4.2)

17 studies reported f/up telephone calls ranging from 1- 7 calls. The duration of the calls was typically around 10 minutes each

11.Soria 2006 {published data only} Soria R,Legido A,EscolanoC, Lopez Yeste A,Montoya J.A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice 2006; 56(531):768–74.

Face-to-Face Versus Telephone

• 7 of the trials delivered by only telephone showed the RR of 1.27 ( 95% CI 1.12 to 1.43; N = 9075; I² = 51%); almost the same as

face to-face counselling (analysis not shown)

(Cigrang 2002; McClure 2005; Hollis 2007; Ellerbeck 2009; Severson 2009; Bastian 2013; Lindqvist 2013)

22

Control vs Intervention (MI)

Control: Self help materials/ in-person smoking health warning & telephone counselling

MI for smoking cessation did show a significant benefit (RR 1.31) (95% CI 1.19 to 1.45; 17 trials, N = 10,966; I² = 54%; Analysis 1.6.2) compared to control group (Face –to-face /telephone smoking cessation support)

MI for smoking cessation did show a significant benefit and (RR 2.25) (95% CI 1.41 to 3.57; 2 trials, N = 945; I² = 0%; Analysis 1.6.3) compared to control group (smoking health warning)

Issues Using MI in Brief Tobacco Cessation Interventions

• Protocol drift

• Cultural and individual factors

• Patient resistance may have a negative effect on a practitioner’s style

Miller W.R., et al. Disseminating evidence-based practices in substance abuse treatment: A review with suggestions. J Substance Abuse Treat 2006;31: 25-39. 24

Key follow-up questions to the readiness ruler can elicit a richer exploration of ambivalence towards cessation:

• Why are you at current score and not 0?

• What you need to do to get from (current score) to (higher score)?

• What has made the thought of quitting smoking this important to you so far, as opposed to it being unimportant (zero)?

• What would it take to make quitting smoking even more important to you?

25

Core Competent In Layman’s Terms

• Try not to argue or to be “pushy”

• Show client you understand his or her perspective

• Be optimistic, supportive and hopeful

• Explore inconsistencies between the “problem” behaviour and the clients goals and value

2 26

THANK YOU