Motivational Behavior Might Help Smokers Quit

A new review of studies says that addressing tobacco use without judging the user appears to help people quit, especially if a primary care physician uses a form of supportive counseling called "motivational interviewing."

The review included data from 14 studies published between 1997 and 2008, with more than 10,000 smokers involved.

"While motivational interviewing has been widely used to help people stop smoking and is recommended in many international anti-smoking guidelines, it had not yet been substantiated by evidence," said lead investigator Douglas Lai, a family medicine specialist in Hong Kong. "This is the first rigorous review of the best evidence available and the result is encouraging."

The review appears in the latest issue of The Cochrane Library, a publication of the Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

In motivational interviewing, the smoker receives non-confrontational counseling intended to help him or her explore conflicts about changing the behavior, identify gaps between smoking and other life goals and support the choice to quit.

The goal is to uncover and resolve ambivalence about quitting. For example, many smokers have never had a chance to discuss, in a non-judgmental setting, their feelings about quitting, such as, "If I stop I''m going to gain weight and I will hate myself if that happens."

According to Stephen Rollnick, Ph.D., and William R. Miller, Ph.D., who developed the strategy, the task of the counselor is to elicit such ambivalent feelings, enable a full expression of all sides of the inner conflict, not judge and help the person find a resolution that includes a choice for attempting smoking cessation.

The method first came about for the treatment of alcohol abuse and has since been used to treat drug addiction and obesity, as well as in asthma and diabetes treatment compliance.

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Trained health care professionals conduct the interventions, which range from a brief 20-minute office visit to multi-session treatment. The studies in the new review included a variety of interventions conducted in different settings, but all relied on the same motivational interviewing principles.

The studies compared outcomes for those who received motivational interviewing and those who received "usual care" of brief advice and pamphlets on smoking cessation.

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All studies recorded post-intervention smoking abstinence data for at least six months. The reviewers found a modest 23 percent increase in smoking cessation among patients who underwent motivational interviewing compared to those who just received usual care.

However, quitting rates were more than three times higher among patients who underwent interviewing with their primary care physician compared to those who did it with another kind of health care worker.

"The fact that primary care physicians had the greatest impact on quit rates when using motivational interviewing - as compared to other subgroups such as hospital clinicians, nurses and counselors - strongly suggests that these doctors can have a significant impact on tobacco use," said Rebecca Schane, M.D., an internist and pulmonologist at the UCSF Center for Tobacco Control Research and Education.

"As it stands," Schane said, "smokers often state that a physician''s support can be one of the most important factors in leading a patient to quit. Physicians need to make time to address smoking in clinical practice. When they do, clearly the outcome is favorable, as we see that patients are nearly four times more likely to quit tobacco when their primary care provider is involved."

Intervention delivered in one session appeared to be as effective as multiple session interventions. Motivational interviewing lasting less than 20 minutes was not effective.

Follow-up telephone calls did not appear to be helpful. The analysis showed that the lowest rate of quitting was associated with a higher number of calls.

Schane said that it is surprising that the review found no added benefit to follow-up telephone contact: "These results are in conflict with many other studies that indicate that the more contact a person has with a health care provider, the more likely they are to quit smoking."



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