Elias M. Klemperer

Working alliance and empathy as mediators of brief telephone counseling for cigarette smokers who are not ready to quit.

Working alliance and empathy are believed to be important components of counseling, although few studies have empirically tested this. We recently conducted a randomized controlled trial in which brief motivational and reduction counseling failed to increase the number of participants who made a quit attempt (QA) in comparison to usual care (i.e., brief advice to quit). Our negative findings could have been due to nonspecific factors. This secondary analysis used a subset of participants (n = 347) to test (a) whether, in comparison to usual care, brief telephone-based motivational or reduction counseling predicted greater working alliance or empathy; (b) whether changes in these nonspecific factors predicted an increased probability of a QA at a 6-month follow-up; and (c) whether counseling affected the probability of a QA via working alliance or empathy (i.e., mediation). Findings were similar for both active counseling conditions (motivational and reduction) versus usual care. In comparison to usual care, active counseling predicted greater working alliance (p < .001) and empathy (p < .05). Greater working alliance predicted a greater probability of a QA (p < .001) but, surprisingly, greater empathy predicted a decreased probability of a QA (p < .05) at the 6-month follow-up. Working alliance (p < .001) and empathy (p < .05) mediated the active counseling’s effects on the probability of a QA. One explanation for our motivational and reduction interventions’ failure to influence QAs in comparison to usual care is that working alliance and empathy had opposing effects on quitting. Our analyses illustrate how testing nonspecific factors as mediators can help explain why a treatment failed.

A Mediation Analysis of Motivational, Reduction, and Usual Care Interventions for Smokers Who Are Not Ready to Quit

Introduction We recently conducted a large randomized controlled trial (RCT) (N = 560) that failed to replicate our initial RCTs findings that brief motivational and reduction interventions increased quit attempts (QA) and point-prevalence abstinence (PPA) in smokers not ready to quit. The present study aimed to test why our interventions were ineffective. Methods A secondary analysis of a 3-arm RCT tested (1) whether telephone-based motivational or reduction interventions changed the following hypothesized mediators more than usual care: cigarettes per day (CPD), dependence, pros of smoking, cons of smoking, self-efficacy, or intention to quit; (2) whether changes in these hypothesized mediators predicted QAs and PPA at a 6-month follow-up, and (3) whether the interventions affected QAs and PPA via the hypothesized mediators. Results In comparison to usual care, the motivational intervention did not significantly influence the hypothesized mediators. The reduction intervention resulted in a significantly greater decrease in CPD and pros of smoking and increase in self-efficacy and intention to quit than usual care. Decreases in CPD and dependence and increases in self-efficacy and intention to quit were associated with increased QAs. The reduction interventions influence on QAs was mediated by decreases in CPD and increases in self-efficacy and intention to quit. Findings regarding PPA were similar. Conclusion Our failure to replicate may be due, in part, to the fact that, compared to usual care, (1) the motivational intervention had no effect on the hypothesized mediators, and (2) the reduction intervention had a statistically significant but clinically insignificant effect on the hypothesized mediators. Implications This study demonstrates that mediation analysis may be useful to understand why an intervention is not more effective than usual care. We identified reductions in CPD and dependence and increases in self-efficacy and intention to quit as predictors of quitting. Further research should focus on developing more effective interventions to target these constructs, and cause clinically significant changes among smokers who are not ready to quit.

Some context for understanding the place of the general educational development degree in the relationship between educational attainment and smoking prevalence.

INTRODUCTION Individuals with a General Educational Development (GED) degree have the highest smoking prevalence of any education level, including high school dropouts without a GED. Yet little research has been reported providing a context for understanding the exception that the GED represents in the otherwise graded inverse relationship between educational attainment and smoking prevalence. We investigated whether the GED may be associated with a general riskier profile that includes but is not limited to increased smoking prevalence. METHOD Data were obtained from three years (2011-2013) of the National Survey on Drug Use and Health ([NSDUH], N=55,940]). Prevalence of risky repertoire indicators (e.g., ever arrested, seldom/never wears a seatbelt), indicators of social instability (e.g., frequent relocations), and risky demographic characteristics (e.g., male gender) were compared among high school dropouts, GED holders, and high school graduates using Rao-Scott chi square goodness-of-fit tests and multiple logistic regression. RESULTS Those with GEDs differed significantly between both high school dropouts and high school graduates across 19 of 27 (70.4%) risk indicators. Controlling for risky profile characteristics accounted for a significant but limited (25-30%) proportion of the variance in smoking prevalence across these three education levels. CONCLUSION GED holders exhibit a broad high-risk profile of which smoking is just one component. Future research evaluating additional risk indicators and mechanisms that may underpin this generalized risky repertoire are likely needed for a more complete understanding of GEDs place in the important relationship between educational attainment and smoking prevalence.

Distal Measurements Can Produce False Negative Results: A Prospective Secondary Analysis of a Natural History Study

Introduction Most prospective studies of quit attempts (QA) or abstinence measure the ability of variables to predict quitting many weeks or months later. This design ignores more proximal fluctuations in the predictor that may be more relevant. The present secondary analysis compares 6-week (distal) and daily (proximal) changes in cigarettes per day (CPD) as predictors of making a QA. Methods Daily smokers reported CPD and QAs nightly throughout a 12-week natural history study. We provided no treatment. In the distal analysis we tested whether reduction in CPD between baseline and 6 weeks predicted making a QA during the following 6 weeks. In the proximal analysis, we identified episodes of one or more days of ≥10% reduction in CPD and tested whether reduction predicted making a QA on the day immediately after the reduction episode. We tested the following predictors: 1) reduction in CPD of ≥10% (yes/no), 2) percent reduction, 3) absolute magnitude of reduction, and 4) CPD at the end of reduction. Results In the distal analysis, reduction did not predict making a QA. In the proximal analysis, any reduction (OR=3.0), greater percent reduction (OR=1.6), greater absolute reduction (OR=1.3), and fewer CPD on the final day of an episode (OR=11.8) predicted making a QA the next day (all p<.001). Discussion Relying on distal measurements to identify causes of a behavior may produce false negative results. Increased use of technological advances will make assessments of the more valid proximal measurements more feasible. Implications This secondary analysis tested distal and proximal predictors of making a quit attempt among the same participants and found that distal tests did not, but proximal tests did predict quit attempts. Relying on distal measurements may result in false negatives.

Reduction in Cigarettes per Day Prospectively Predicts Making a Quit Attempt: A Fine-Grained Secondary Analysis of a Natural History Study

INTRODUCTION Reducing cigarettes per day (CPD) aided by medication increases quit attempts (QA) among smokers not trying to quit. If this is due to reducing CPD per se, then a greater reduction should predict making a QA. AIMS AND METHODS In this secondary analysis, 132 smokers completed nightly calls to report CPD, intention to quit tomorrow, and QAs over 12 weeks. We provided no treatment. We identified episodes of reduction and tested whether (1) percent reduction in CPD, (2) absolute reduction in CPD, (3) duration of reduction, or (4) CPD on the final day predicted a QA immediately after a reduction episode. We tested this separately among reduction episodes that began with and without an intention to quit. RESULTS Among the 1179 episodes that began without intention to quit, all four measures of reduction predicted making a QA. Greater percent reduction, longer duration, and fewer CPD on the final day were retained in a multivariate model (all p < .05). Among the 85 episodes that began with intention to quit, greater percent reduction and greater absolute reduction predicted making a QA. Only mean percent reduction was retained in a multivariate model (p < .001). CONCLUSIONS Our results replicate and extend earlier studies by using fine-grained analyses and examining immediately proximal QAs in a sample of self-quitters. Findings suggest that reducing CPD per se increases the probability of a QA among smokers without intention to quit in a dose-related manner. Whether this is the case among smokers who intend to quit remains unclear. IMPLICATIONS Reducing CPD appears to be an effective strategy to increase the probability of making a QA for the majority of smokers who do not intend to quit in the near future. However, our findings are mixed regarding the effectiveness of reducing among smokers who intend to quit. Clinical interventions and policies that promote reducing CPD are likely to be an effective way to increase QAs. Reduction may be especially helpful for smokers who have not responded to traditional advice to stop abruptly.

After precessation nicotine replacement therapy, abrupt cessation increases abstinence more than gradual cessation in smokers ready to quit

Commentary on: Lindson-Hawley N, Banting M, West R, et al. Gradual versus abrupt smoking cessation a randomized, controlled noninferiority trial gradual versus abrupt smoking cessation. Ann Intern Med 2016;164:585–92[OpenUrl][1][CrossRef][2][PubMed][3]. Most guidelines recommend abrupt smoking cessation; however, gradual cessation is common. Reducing cigarettes per day (CPD) with nicotine replacement therapy (NRT) increases cessation among smokers who are not ready to quit.1 However, whether gradual reduction is effective for smokers who want to quit now is unclear.2 This randomised controlled trial compared gradual cessation (ie, reduction in CPD) with abrupt cessation among smokers ready to quit (N=697). The gradual-cessation group received 2 weeks of NRT patches, short-acting … [1]: {openurl}?query=rft.jtitle%253DAnn%2BIntern%2BMed%26rft.volume%253D164%26rft.spage%253D585%26rft_id%253Dinfo%253Adoi%252F10.7326%252FM14-2805%26rft_id%253Dinfo%253Apmid%252F26975007%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.7326/M14-2805&link_type=DOI [3]: /lookup/external-ref?access_num=26975007&link_type=MED&atom=%2Febmed%2F21%2F5%2F174.atom