Motivational Interviewing as a Smoking Cessation Intervention for Patients With Cancer

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Table of Contents

Overview of the Study
Literature Review
References:

Overview of the Study

The study is a randomized control study by Melanie Wakefield and her team of researchers including Ian Olver, Hayley Whitford, and Ellie Rosenfield. Melanie Wakefield, Ph D., is the Director at the Centre for Behavioral Research in Cancer, Cancer Council of Victoria, Carlton, Australia. Ian Olver Ph D. is the Clinical Director; Hayley Whitford Ph D. is the Senior Behavioral Scientist while Ellie Rosenfield, MPH is the Research Officer, Royal Adelaide Hospital Cancer Centre, Adelaide, South Australia. References are adequately entered in the APA format. The title says “Motivational interviewing as a smoking cessation intervention for patients with cancer”

The research paper has been published in the Nursing Research, November/December 2004, in Vol 53 in issue No. 6 as pages 396 to 405.

The study is experimental and quantitative with a control group and longitudinal in nature. The criterion variable is motivational interviewing. The dependent variable is the cessation of smoking in 3 months of the interventions. The population covered includes 137 patients cancer-treated patients attending a South Australian Hospital.

The abstract is adequately informative and the background idea is specific. The study is based on the author’s belief that cessation of smoking influences cancer-treated patients by improving the efficacy of treatment. The intention is to test her idea by motivationally interviewing these patients attending a South Australian Public Hospital and comparing the results with another group of treated cancer patients who would not be interviewed.137 patients with mixed cancer sites would be studied. 74 were subjected to motivational intervention. The control group of 63 was given minimal advice and no motivational interviewing intervention.

The study covered 3 months. The interventions were a visit with a counselor, booklets, nicotine replacement therapy, family advice, and telephonic conversations. At the 6 month visit, it was found that no difference existed between the 2 groups, 5% & 6%, in terms of quit rates within the 3 months. A more lenient comparison showed 29% for the rate of quitters in the intervention group and 18% for the other group. She suggests more direct methods the next time a study in this direction is done. This may include spouse cessation of smoking, use of bupropion, and support to the patient.

Problem Statement

Smoking has been known to be the cause of lung cancer. Many patients of cancers of any site of origin are known to be careless in their life following the initial therapy. Probably believing that their smoking was not a reason for their type of cancer, they throw caution

to the winds and persist in their pursuit of smoking. Research has shown that they stand the risk of recurrence and the risk of getting a second primary cancer and the life span being shortened. This study compares the effects of the motivational interviewing intervention on the smoking habit of a group of already treated cancer patients in a South Australian hospital using a control group too of treating cancer patients who are not motivated against smoking.

Statement of Purpose

The study is conducted to determine whether a motivational interviewing intervention increased successful cessation attempts at smoking in cancer patients attending a South Australian public hospital, as compared to the attempts by those cancer patients who had only the usual care. The statement of purpose is aptly worded and gives a definite picture of the study undertaken.

Literature Review

The literature review is relevant in context and the author has worked her way from a broader concept of speaking about the efficacy of cancer treatments being compromised by the smoking habit and narrowed it to the concept of motivational interviewing and its probable good for improving the quality of life for these patients. The various instances where smoking has produced a negative effect and prognosis are quoted from the researches of earlier scientists.

An increased rate of side effects of treatment, higher anesthesia-related risks, impaired wound healing, and greater weight loss in lung cancer patients has been reviewed. A suggestion that says that a patient treated for cancer at an early post-treatment stage would be ‘teachable’ is mentioned. This could be utilized for motivation towards cessation of smoking. This salient point forms the basis for endeavoring this study. Caution has been pointed out about approaching the patients as they could be upset about their condition and may deny the relationship of smoking to their state of health. This useful piece of advice has been heeded here.

The review speaks of using motivational interviewing to show the discrepancies between actual and ideal behavior. The significance of combining the Prochaska and DiClementes Transtheoretical model of change and Rollnick and Miller’s motivational interviewing techniques (Rollnick and Miller, 1995) is highlighted much within the context of this study. Further, the significance of using pharmacological adjuncts (nicotine replacement therapy or NRT) along with motivational interviewing is mentioned here. The importance of passive smoking has also been mentioned. Wives and other relatives could be encouraged to cease smoking as has been revealed in a study.

The US Public Health Services has concluded that a combination of therapies including practical counseling with intra and extra supportive measures along with pharmacotherapies seem to be the best therapy treatment of tobacco abuse and dependence. The literature review does contribute to the idea behind this study. Motivational interviewing, NRT, advice to family members to quit smoking in support of the patient could affect the cessation of smoking.

The well-organized literature review which is logical, comprehensive, and relevant to the problem leads to the research purpose, the relationship to which is evident. The paper being of the year 2004 has included reviews of recent researches of the year 2000. A case has been made for conducting this study based on the review.

Theory /Framework

The logistics regression model has been used where the response variable of interest is the cessation of smoking in the intervention group and control group assessed at a 6-month follow-up, after combining the groups. An analysis was done to determine which variables were associated with the cessation. Cessation for 7 days was taken as the outcome measure and this group was designated the intention-to-treat group. Predictor variables showing univariate associations with p values of 0.25 were assessed. The model was reliably different from a constant-only model. The variance in the quit status was 36% and the model classified 86 % of cases as quit or not. Those who had quit were more likely to have cancer-related to smoking.

The concepts to be studied have been identified and defined. Both the groups were assessed the same way at the 6-month follow-up. 4 decreasingly stringent outcomes were used to compare the intervention and control groups The groups had patients who had stopped smoking within 3 months and whose biochemical results confirmed the nonsmoking status (a urine sample for cotinine analysis being negative or breath for Carbon monoxide level less than 8 parts per million); patients who stopped smoking but had no confirmatory results, patients who had stopped for the last seven days with confirmatory results and another group who had stopped during the last 7 days but had no confirmatory results. Measures have been identified and described. The secondary variables for patient outcome were the patients’ attempts to quit and the changes in daily cigarette consumption from baseline.

The logistics regression model is the model applied in most Nursing researches.

The dependent variable would usually be dichotomous. The independent variable or the predictor variables could be in any form.

Research Question

The objective is to determine whether a motivational interviewing intervention increased successful smoking attempts in treated cancer patients in a South Australian cancer hospital.

The hypothesis statement is thus: “in comparison to control patients, the patients receiving the tailored smoking cessation interventions would have a significantly higher quit rate at the 6-month follow-up assessment”

Both the research objective and the hypothesis have been formally stated, and they flow naturally from the research problem and theoretical framework. The research has sufficient variables (6), smoking-related cancer site, radiation therapy, surgery, number of quit attempts, family whether encouraging or not, and the stage of quitting, pre-contemplator, contemplator, and preparation (Behavior Change Spiral, 1996). The hypothesis and objective are worded.

Study Design

A randomized control study has been done. Demographic, personal and smoking habits have been used to ensure that randomization has been good in this study. Enough information has been obtained for replication.

The target population was well described and sample selections were made with criteria for eligibility. Patients were selected over 20 months from May 1999 by doctors in the radiology, medical oncology, and hematology departments. The criteria for eligibility were that the patient had a diagnosis of cancer with a prognosis of more than 6 months and smoked tobacco more than once weekly. He had to speak English and have enough cognitive awareness to consent. He had to be living close to the hospital. This was for biochemical confirmation tests. Later, distance from the hospital was ignored so that enough participants were found.

The types of cancers included in the study were smoking-related ones including lung (12%), head and neck (17%), bladder (2%), breast (13%), prostate (9%), colon(10%), leukemia (10%), lymphomas( 15%), testicle(4%) and others. Most were heavy smokers and 40% had a spouse who smokes. Out of many falling within the criteria, 137 remained for the study. The sample is sufficiently large.

Data collection was through a baseline questionnaire. Their intentions for cessation of smoking were in line with DiClemente and Prochaska’s stages of change and Rollnick and Miller’s motivational interviewing techniques. This technique employs less rigid cessation and greater flexibility which would be relevant in this study which includes patients who are having a fatal illness though treated. Patient listening, empathy, and feedback using nonconfrontational and supportive motivational techniques would be best and have been utilized here. The rationale for selecting this technique is thus explained.

Data were analyzed using the Statistical Package for the Social Sciences, Version 11.5. The difference of the groups across the variables was checked using Fisher’s exact tests and x². The power to detect medium effects was almost similar using the t-tests (80%) and the x²(70%). The predictors of cessation of smoking were analyzed by the binary logistics regression method. There is a possibility of replication in this study. The analysis is expressed clearly within the text as well as numerically in the tabular form…

The intervention was delivered by the trial coordinator who spent an average of 209 +/- 188.4 minutes with each patient over the study. 74 patients in the intervention group were given specific advice and booklets with the advice for cancer patients to stop smoking. Telephonic and in-person motivational interviewing was also given. Only 49 intervention patients out of the 74 who began could be followed up at the 6^th month. The 63 patients in the control group were given brief advice to quit, widely available brochures, and a phone number of the state-based telephone quit-line service if they wished for further assistance. Of these, only 39 were available for the 6-month follow-up.

70% found the written information for quitting smoking useful. 91% affirmed that the trial coordinator called them at the right time for the telephonic follow-up. 84 % agreed that they had optimum calls. 87% felt they were not pressurized to quit. 96% of patients thought that the trial coordinator understood them well and that the program was acceptable.

The conclusion said that the motivational interviewing intervention was unsuccessful in promoting the cessation of smoking or reducing cigarette consumption.

Limitations of the study

The accrual of patients was dependent on the physicians who had more demanding commitments other than this study. So there was a delay in getting sufficient patients to participate. Had there been a separate person who was solely dedicated to the accrual of patients, the effect would have been more pronounced. Future trials should attend to this drawback. Only 45% of eligible patients participated as many did not consider cessation of smoking a priority in their remaining life. Biochemical confirmation could not be obtained from more than half of the participants. However, it did not matter here as no benefit was seen in the intervention group.

Many patients were lost to evaluation at the 6^th month. 21.4% could not be contacted. 15% had died. The cessation rates were lower than in earlier studies (Gritz, 1993). In the earlier study, cancers were mostly related to smoking. Although the patients were appreciative of the program, this attitude did not translate into greater cessation of smoking. The use of NRT did not affect the outcome.

The study had been approved by the Ethics Committee of the Royal Adelaide Hospital. All patients gave informed consent before participating.

To summarise, this paper has been well written with no grammatical or spelling, or punctuation mistakes. The APA format has been adopted as the style of writing. In-text citations are well placed. The reference list suggests vast research before writing this paper. No specific recommendations have been made for the nursing profession. However, the paper could be taken as an example for future reference. The limitations of this study help the preparation for later research.

References:

Behavior Change Spiral, AFAO, 1996. Web.

Gritz, E.R.et al; (1993), “Predictors of long term smoking cessation in head and neck cancer patients”, Cancer Epidemiology, Biomarkers and Prevention, 2, Pgs.261-270.

Rollnick, Stephen and Miller, R.William; (1995), “What is motivational interviewing” Behavioral and Cognitive Psychotherapy, Vol 23, Pgs. 325-334.

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