Motivating the unmotivated for health behavior change: A randomized trial of cessation induction for smokers

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Hollings Cancer Center,86 Jonathan Lucas St., PO Box 250955, Charleston, SC 29425, USA.
Clinical Trials (Impact Factor: 1.93). 03/2010; 7(2):157-66. DOI: 10.1177/1740774510361533
Source: PubMed


Many smokers remain unwilling or unable to make a quit attempt. For these smokers, novel strategies to induce quit attempts are necessary to achieve further reductions in smoking prevalence.
This article describes the design and methods of an ongoing nationwide telephone-based clinical trial for cessation induction, the principal aim of which is to test the hypothesis that samples of nicotine replacement therapy (NRT), can induce quit attempts among smokers otherwise unmotivated to quit.
Smokers are recruited proactively through online channels. A 'behavioral filter' is used to identify and separate motivated versus unmotivated smokers, the latter of whom (N = 750) are formally entered into the clinical trial. Participants are randomized to one of two treatment conditions designed to promote self-efficacy and motivation to quit: (1) practice quit attempt (PQA) or (2) PQA plus NRT sampling. The primary outcome measure tested over a 6-month follow-up is the incidence of additional quit attempts as well as hypothesized mediators of treatment effects.
This study details the challenges of identifying and treating smokers who are unmotivated to quit. Strengths include a novel treatment approach, tested among a group of proactively recruited smokers nationwide, with a unique method of identifying cessation-resistant smokers.
The omission of a true control group, testing the effect of the PQA itself, is an inherent limitation to the study design. Online recruitment presents additional study challenges, all of which are discussed in detail.
The study has translational potential to guide both clinical and policy recommendations for cessation induction. Further, while the focus is on smoking, this trial may serve as an example to researchers and clinicians who focus on other health behaviors, and who themselves are challenged with motivating people who are unmotivated for change.

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    • "The pilot RG intervention is guided by the Transtheoretical Model, which conceptualizes individual stages of change to both understand and modify behavior (W.F.Velicer, Prochaska, Fava, Laforge, & Rossi, 1999). However the RG also incorporates a practice quit attempt, similar to the cognitive-behavioral concept of a behavioral experiment, in which the participant rehearses a particular behavior (Carpenter et al., 2010). In the incentive condition, the RG intervention incorporates behavioral theory and operant conditioning (Stitzer, Petry, & Peirce, 2010). "
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    ABSTRACT: This study implemented a smoking cessation Readiness Group (RG) in two women-focused residential substance abuse treatment programs, with the aim of engaging women in smoking cessation services. The primary outcome was defined as attending at least one cessation group after the RG ended. The RG combined features of the Expert Systems (ES) approach with a practice quit attempt. ES is an interactive system which tailors intervention to the smokers’ stage of change, while the practice quit attempt rehearses the process of quitting smoking. As a secondary aim we tested whether incentives, used to promote participation and engagement in the RG, would increase initiation of smoking cessation services. Participants (N = 75) were women smokers enrolled in two residential programs, and intention to quit smoking was not required for participation. Twelve participant cohorts were randomly assigned to receive the RG with or without incentives. Following the RG intervention, 38.7% of participants (n = 29) attended at least one smoking cessation session. Both the number of RG sessions attended and a successful practice quit attempt predicted the later use of cessation services, while incentives did not. From pre to post RG, participants reported decreased cigarettes per day (CPD: 11.8 v. 7.6, p < .0001) and decreased nicotine dependence as measured by the Heaviness Smoking Index (HSI: 2.3 v. 1.8, p < .001). The 3-session group-format RG intervention was associated with initiation of smoking cessation services and with changes in smoking behavior.
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    • "Another explanation was that 1-week free NRT was enough to encourage motivated smokers to continue to use it for a longer duration, because some smokers who attended the clinic were already motivated to quit and giving 1-week or 2-week supply did not have any measurable effect on their determination to quit and buy NRT afterwards. This further reflects the importance of self-motivation in quitting smoking [29]. Also, the price of NRT as compared to the price of the cigarettes is an important consideration for smokers. "
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    ABSTRACT: This study examined if 2-week free nicotine replacement therapy (NRT) would be more effective than 1-week free NRT to help smokers quit smoking at 6 and 12 months. In a single-blinded randomized controlled trial design, 562 Chinese smokers who attended a smoking cessation clinic in Hong Kong, China, were randomly allocated into two groups (A1 and A2): A1 (n = 284) received behavioural counselling with free NRT for 1 week; A2 (n = 278) received similar counselling with free NRT for 2 weeks. All subjects received printed self-help materials to support their quitting efforts. A structured questionnaire was used for data collection, including pattern of NRT use and self-reported 7-day point prevalence quit rate at 6 months and 12 months. Among the participants, the mean number of cigarettes smoked per day was 18.8 (SD = 10.9). By intention-to-treat analysis, 7-day point prevalence quit rates were not significantly different between A1 and A2 groups at 6-month (27.5% versus 27.3%; P = 0.97) and 12-month (21.1% versus 21.2%; P = 0.98) followup. The findings suggest that two-week free NRT was not more effective than 1-week free NRT to increase smoking cessation rate among Chinese smokers.
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    • "As a result, our study was not powered on clinical outcomes of more direct interest such as quit attempts and cessation. While we acknowledge this as a limitation, we also believe it is always necessary to first demonstrate the feasibility of an approach before expending the vast amount of resources typically required for a cessation study (Carpenter et al., 2010 "
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    ABSTRACT: PLHIV have higher rates of smoking and lower motivation to quit smoking; thus to impact smoking rates, cessation interventions need to be acceptable to a wider range of PLHIV smokers as well as feasible to implement in a busy clinical setting. The purpose of this study was to evaluate the acceptability, feasibility, and effects of a Screening, Brief Intervention, and Referral for Treatment (SBIRT) model in an HIV/AIDS clinic among a sample of PLHIV. PLHIV smokers (N=40) were randomized at baseline, irrespective of their self-reported discrete smoking cessation motivation status, to receive either 8-weeks of combination nicotine replacement therapy (NRT) in conjunction with brief counseling (SBIRT framework) (n=23) or usual care (n=17). Smoking outcome measures included cigarettes smoked per day, nicotine dependence, smoking urge, and smoking withdrawal symptoms. The SBIRT intervention appeared to be acceptable and feasible, and produced medium to large reductions in cigarettes smoked per day, physical nicotine dependence, smoking urge, and smoking withdrawal symptoms, even for smokers not ready to quit within 6months. Findings provide preliminary support for the integration of an SBIRT model in an HIV/AIDS clinic setting to screen and provide active treatment to all smokers, regardless of readiness to quit smoking. Given the high prevalence and incredible health burden of continued smoking in this population, identifying brief and effective interventions that are easily translated into clinical practice represents an enormous challenge that if met, will yield significant improvements to overall patient outcomes.
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