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BMC Public Health
Published in: BMC Public Health 1/2016

Open Access 01-12-2016 | Research article

A randomized controlled trial of directive and nondirective smoking cessation coaching through an employee quitline

Authors: Walton Sumner II, Mark S. Walker, Gabrielle R. Highstein, Irene Fischer, Yan Yan, Amy McQueen, Edwin B. Fisher

Published in: BMC Public Health | Issue 1/2016

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Abstract

Background

Telephone quitlines can help employees quit smoking. Quitlines typically use directive coaching, but nondirective, flexible coaching is an alternative. Call-2-Quit used a worksite-sponsored quitline to compare directive and nondirective coaching modes, and evaluated employee race and income as potential moderators.

Methods

An unblinded randomized controlled trial compared directive and nondirective telephone coaching by trained laypersons. Participants were smoking employees and spouses recruited through workplace smoking cessation campaigns in a hospital system and affiliated medical school. Coaches were four non-medical women trained to use both coaching modes. Participants were randomized by family to coaching mode. Participants received up to 7 calls from coaches who used computer assisted telephone interview software to track topics and time. Outcomes were reported smoking abstinence for 7 days at last contact, 6 or 12 months after coaching began. Both worksites implemented new tobacco control policies during the study.

Results

Most participants responded to an insurance incentive introduced at the hospital. Call-2-Quit coached 518 participants: 22 % were African-American; 45 % had incomes below $30,000. Income, race, and intervention did not affect coaching completion rates.
Cessation rates were comparable with directive and nondirective coaching (26 % versus 30 % quit, NS). A full factorial logistic regression model identified above median income (odds ratio = 1.8, p = 0.02), especially among African Americans (p = 0.04), and recent quit attempts (OR = 1.6, p = 0.03) as predictors of cessation. Nondirective coaching was associated with high cessation rates among subgroups of smokers reporting income above the median, recent quit attempts, or use of alternative therapies. Waiting up to 4 weeks to start coaching did not affect cessation. Of 41 highly addicted or depressed smokers who had never quit more than 30 days, none quit.

Conclusion

Nondirective coaching improved cessation rates for selected smoking employees, but less expensive directive coaching helped most smokers equally well, regardless of enrollment incentives and delays in receiving coaching. Some subgroups had very low cessation rates with either mode of quitline support.

Trial registration

ClinicalTrials.gov NCT02730260, Registered March 31, 2016
Footnotes
1
Supervisor Survey
Smoking prevalence among school employees was unknown, but less than 10 % of employees admitted smoking on health surveys. We conducted a supervisor survey at the school from January to March 2011 to independently estimate smoking prevalence. Top-level department administrators received a survey. Survey recipients who directly or indirectly supervised more than 30 individuals were to report only on directly supervised employees and forward a blank survey to the supervisors amongst them. The survey thus cascaded through tiers of supervisors. At each tier, survey recipients anonymously reported the top-level department name, how many staff they supervised, how many primary appointment faculty they served, and how many smokers were in each group.
Survey responses covered 52 % of employees. Only 369 (7.3 %) of 5,030 staff and 21 (1.4 %) of 1534 faculty members were identified as smokers, in agreement with other smoking prevalence estimates. These data implied that about 530 medical school employees smoked. The very low prevalence of smoking at the school explains most of the difference in enrollment between the school and the hospital.
 
2
Training Procedures
Training of phone coaches entailed each of the following elements:
  • Didactic presentations by MW, EF, GH, WS, and worksite employee health representatives.
  • Readings regarding the substantive areas addressed during in-service training, including 7 Steps to a Smoke-Free Life (E. Fisher, Wiley, 1998) and How to Quit Smoking without Gaining Weight (B. Marcus, J. Hampl, & E. Fisher, Pocket Books, 2004), and Motivational Interviewing: Helping People Change (W. Miller, S. Rollnick, 2012).
  • Meetings with experienced peer coaches and other intervention workers who were involved in other research at Washington University (R21 CA 10172-01; R01 HL 72919).
  • Role play of telephone counseling interactions
  • Closely supervised pilot implementation of the protocols with initial participants
Training Content Areas
Training of the phone coaches included content in the following areas:
  • Two protocols for directive and nondirective interventions, rationales for their comparison, and key distinction between them
  • Fundamental skills in counseling and provision of support
  • Assessment of readiness to quit smoking, incorporating assessment of readiness into counseling, and tactics for promoting key behaviors appropriate to the patient’s readiness to change
  • Characteristics of smoking and key factors in smoking cessation
  • Strategies for addressing barriers to smoking cessation and to maintenance of abstinence after cessation
Ongoing Supervision
Supervision of the telephone coaches included the following:
  • Weekly meetings with GH to address issues that arise as part of the intervention
  • As needed supervisory meetings with GH and MW or WS to assess problems and progress in meeting coaches’ training needs
  • Periodic review of the elements of training listed above
  • In service didactic presentations by key personnel to address intervention issues that arose during the study
Protocols for training and supervision of coaches were reviewed by a medical advisor, worksite employee health representatives, and MW and EF.
Computer-Based Intervention Prompting, Monitoring & Documentation
Coaches were taught to use software tools for identifying and tracking calls and documenting call content. Laptop computer software prompted and monitored all coaching contacts and attempted contacts with participants. Records included the nature of each contact (protocol based call, patient-initiated unscheduled call, left message, attempted but unsuccessful call), duration of call, assessed stage, topics covered, and plans for next contact. Contact records were synchronized regularly to support identification of overdue contacts, quality control and supervision of the coaches, and daily updates of newly enrolled participants. During calls, the laptop software also prompted coaches with specific suggested questions to ask and “talking points” for each topic and behavior.
Control of Intervention Differences
In designing the study, we considered varied approaches to fidelity to the planned interventions and to controlling differences between them. Assigning one or several phone coaches to each condition risked confounding differences between interventions with personality or skill differences between the coaches. We therefore explained to coaches in detail the reasons for the study and the potential pros and cons of directive and nondirective coaching so that they would implement each coaching mode with full commitment to its value for participants, recorded all calls, reviewed many calls, and transcribed and analyzed a subset of calls.
 
3
Imputing missing income data
Missing income data in 29 records were singly imputed using two classification and regression trees. The more accurate tree used marital status, education, age at baseline, sex, race, body mass index, and job rank as classifiers. Splits were made until the tree reached an R2 of 0.8, then leaves with 3 or fewer observations were pruned. The second tree was similar except that it omitted body mass index and job rank, which also were missing in 9 records, and splits were stopped at an R2 of 0.6. Missing income values were imputed as the most probable value in the first CART, or the second CART if the first required missing data. In records with complete data, this algorithm classified income correctly in 81 % of cases, with an R2 of 0.39.
 
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Metadata
Title
A randomized controlled trial of directive and nondirective smoking cessation coaching through an employee quitline
Authors
Walton Sumner II
Mark S. Walker
Gabrielle R. Highstein
Irene Fischer
Yan Yan
Amy McQueen
Edwin B. Fisher
Publication date
01-12-2016
Publisher
BioMed Central
Published in
BMC Public Health / Issue 1/2016
Electronic ISSN: 1471-2458
DOI
https://doi.org/10.1186/s12889-016-3202-y

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