Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers

Abstract

BackgroundCurrent guidelines advise providers to assess smokers’ readiness to quit, then offer cessation therapies to smokers planning to quit and motivational interventions to smokers not planning to quit.ObjectivesWe examined the relationship between baseline stage of change (SOC), treatment utilization, and smoking cessation to determine whether the effect of a proactive smoking cessation intervention was dependent on smokers’ level of motivation to quit.DesignSecondary analysis of a multicenter randomized controlled trial.ParticipantsA total of 3006 current smokers, aged 18–80 years, at four Veterans Affairs (VA) medical centers.Interventions: Proactive care included proactive outreach (mailed invitation followed by telephone outreach), offer of smoking cessation services (telephone or face-to-face), and access to pharmacotherapy. Usual care participants had access to VA smoking cessation services and state telephone quitlines.Main MeasuresBaseline SOC measured with Readiness to Quit Ladder, and 6-month prolonged abstinence self-reported at 1 year.Key ResultsAt baseline, 35.8 % of smokers were in preparation, 38.2 % in contemplation, and 26.0 % in precontemplation. The overall interaction between SOC and treatment arm was not statistically significant (p = 0.30). Among smokers in preparation, 21.1 % of proactive care participants achieved 6-month prolonged abstinence, compared to 13.1 % of usual care participants (OR, 1.8 [95 % CI, 1.2–2.6]). Similarly, proactive care increased abstinence among smokers in contemplation (11.0 % vs. 6.5 %; OR, 1.8 [95 % CI, 1.1–2.8]). Smokers in precontemplation quit smoking at similar rates (5.3 % vs. 5.6 %; OR, 0.9 [95 % CI, 0.5–1.9]). Within each stage, uptake of smoking cessation treatments increased with higher SOC and with proactive care as compared with usual care.LimitationsMostly male participants limits generalizability. Randomization was not stratified by SOC.ConclusionsProactive care increased treatment uptake compared to usual care across all SOC. Proactive care increased smoking cessation among smokers in preparation and contemplation but not in precontemplation. Proactively offering cessation therapies to smokers at all SOC will increase treatment utilization and population-level smoking cessation.

Predicting Engagement in Smoking Cessation Treatment Following a Brief Telephone Evaluation and Referral Session

“…For example, Japuntich and colleagues (2017) found that proactive care resulted in a smaller effect on prolonged abstinence rates for those with than without a mental health diagnosis. Within this same trial, there were differences by readiness to change and treatment condition such that participants in the contemplation and preparation stages of change who received the proactive intervention had better abstinence outcomes than those in usual care (Danan et al, 2016). These findings support encouraging treatment utilization regardless of current SOC.…”

“…Subsequently, a hierarchical logistic regression analysis was conducted to examine predictor relations for the outcome of interest, engaging in at least one smoking cessation treatment session within 30 days of call participation (yes or no). The first step of the regression included demographics and smoking-related variables (cigarettes per day, SOC, importance and confidence in quitting) that have previously been found related with treatment utilization(Danan et al, 2016;Fu, van Ryn, Sherman, et al, 2014;Myers et al, 2016;Myers et al, 2015). Demographic variables are presented by frequencies and percentages for categorical variables and means (deviation [SD]) for continuous variables.…”

Association of the Affordable Care Act With Smoking and Tobacco Treatment Utilization Among Adults Newly Enrolled in Health Care

“…As historically medically underserved patients are increasingly treated in accountable care organizations and other multi-specialty and integrated health care systems, it will be important to develop tailored outreach, education, and enrollment efforts to and engage newly insured smokers. (35) Continued monitoring of the association of insurance coverage with use of tobacco treatments and subsequent smoking cessation will help determine whether the promise of health reform for reducing disparities in tobacco use has been met.…”

Capsule Commentary on Danan et al., Does Motivation Matter? Analysis of a Randomized Trial of Proactive Outreach to VA Smokers

“…1 Using the transtheoretical model of behavioral stages of change (SOC), they assessed veterans' readiness to quit smoking after categorizing them under precontemplation, contemplation, and preparation phases while receiving either usual or proactive care. SOC was assessed at baseline and follow-up with the 10-point Readiness to Quit Ladder (RQL).…”