Nurses are well placed to support smoking cessation. This summary outlines the nursing implications of a recent Cochrane review on motivational interviewing
Keywords Psychological interviews, Motivational interviewing, Smoking cessation
What is the best available evidence for motivational interviewing as a strategy for smoking cessation compared with “brief advice” or “usual care”?
It is well known that smoking is associated with lung cancer, chronic obstructive pulmonary disease (COPD), ischaemic heart disease and cardiovascular disease. As a result, government policies and primary healthcare strategies encourage smoking cessation initiatives to reduce the health and economic burden associated with smoking.
Restrictions on where people are permitted to smoke, the sale and advertising of tobacco, combined with smoking cessation strategies that include counselling and medications have been introduced to help people to quit smoking. However barriers to implementing cessation strategies include nurses’ lack of knowledge about tobacco control guidelines and lack of skills to undertake smoking cessation interventions.
Motivational interviewing has been used successfully to facilitate behavioural change with people who express an interest in giving up smoking, and could be implemented by nurses in a variety of clinical settings. The technique avoids a confrontational approach when providing advice or discussing strategies for smoking cessation.
A systematic review completed in 2009 of 14 trials (n = 10,538) was performed to evaluate the benefits of smoking cessation programmes using motivational interviewing as an intervention compared with “usual care” or “brief advice”. The studies were randomised controlled trials and cluster-randomised controlled trials. Two noted inadequate sequence generation or allocation concealment, while five did not confirm blinding of the outcome assessment. The lack of blinding was attributed to the nature of the behavioural intervention which meant that blinding of participants and the intervention was not always possible.
Participants were tobacco users of either gender; pregnant women and adolescents were excluded as they were deemed to require an intervention specific to their requirements. An age limit was not applied in the review but the mean age from each trial was provided. The motivation to participate in a smoking cessation programme was only addressed with participants by two studies.
The intention of motivational interviewing to support smoking cessation was to provide feedback to the smoker where they were encouraged to explore the difference between their personal goals and smoking. The criteria for motivational interviewing had to include all or some of the following guiding principles: expressing empathy, developing discrepancy, rolling with resistance and supporting self-efficacy. The intervention was compared with “usual care” or “brief advice”. Usual care was defined as brief advice with a stop smoking message which may have included information about the harmful effects of smoking or routine care. The length of time required to deliver the usual or routine care was not defined.
Each study interpreted and used the principles of motivational interviewing differently which made the comparison between studies difficult. Interviews were delivered by GPs, hospital doctors, nurses, counsellors or psychologists. Training for the provider was provided through workshops in 11 studies. Three studies delivered the intervention by telephone while the remainder provided face-to-face sessions.
The main outcome of interest in the review was abstinence from smoking at six months or more. Participants lost to follow-up were classed as continuing smokers. Abstinence was confirmed chemically by nine of the trials.
Summary of key evidence
The key result of motivational interviewing vs. ‘brief advice’ or ‘usual care’ demonstrated a small significant increase in abstinence at six months or more (relative risk (RR) 1.27, 95% confidence interval (CI) 1.14–1.42). However, additional components used alongside motivational interviewing may have enhanced its effectiveness for example, pharmacotherapy including nicotine replacement therapy and written and audiovisual materials.
Most studies that implemented motivational interviewing sessions of over 20 minutes showed significantly more benefit than shorter sessions (RR 1.31, 95% CI 1.16–1.49). Motivational interviewing delivered by GPs appeared to yield better success rates (RR 3.39, 95% CI 1.53–7.94) and this was attributed to the often long-term doctor-patient relationship. It was unclear what the optimal number of sessions may be or how follow-up sessions might support smoking cessation decisions and adherence.
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Best practice recommendations
- Motivational interviewing may assist smokers to quit, but differences in interpretation mean the results need to be treated cautiously.
- People need to be assessed for their motivation, interest and commitment to undertaking a smoking cessation intervention.
- Motivational interviewing avoids an aggressive or confrontational approach to encouraging people to quit smoking and may be more likely to support long term adherence to a cessation programme.
- Motivational interviewing may be an effective strategy for nurses to use in supporting smoking cessation if sessions last longer than 20 minutes.
- It would be crucial to monitor the impact of motivational interviewing on smoking cessation rates through careful attention to defining the techniques used.
DENISE BLANCHARD, PhD, RN, is assistant professor nursing and midwifery, Faculty of Health, University of Canberra and a member of the Cochrane Nursing Care Field
Lai DTC et al (2010) Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD006936. DOI: 10.1002/14651858.CD006936.pub2.