Patient Education
What mediates the effect of confrontational counselling on smoking cessation in smokers with COPD?

https://doi.org/10.1016/j.pec.2008.11.017Get rights and content

Abstract

Objective

Within the framework of a randomized, active treatment controlled trial, we used a mediation analysis to understand the mechanisms by which an intervention that uses confrontation with spirometry for smoking cessation achieves its effects.

Methods

Participants were 228 smokers from the general population with previously undetected chronic obstructive pulmonary disease (COPD), who were detected with airflow limitation by means of spirometry. They received two equally intensive behavioural treatments by a respiratory nurse combined with nortriptyline for smoking cessation: confrontational counselling with spirometry versus conventional health education and promotion (excluding confrontation with spirometry and COPD).

Results

Cotinine validated abstinence rates from smoking at 5 weeks after the target quit date were 43.1% in the confrontational counselling group versus 31.3% in the control group (OR = 1.67, 95%CI = 0.97–2.87). The effect of confrontational counselling on abstinence was independently mediated by the expectation of getting a serious smoking related disease in the future (OR = 1.76, 95%CI = 1.03–3.00), self-exempting beliefs (OR = 0.42, 95%CI = 0.21–0.84), and self-efficacy (OR = 1.38, 95%CI = 1.11–1.73).

Conclusion

We conclude that confrontational counselling increases risk perceptions and self-efficacy, and decreases self-exempting beliefs (risk denial) in smokers with previously undetected COPD. These changes in mediators are associated with a higher likelihood of smoking cessation.

Practice implications

Apart from the intensity, the content of smoking cessation counselling may be an important factor of success. A confrontational counselling approach as we applied may have the potential to alter smoking-related cognitions in such a way that smokers are more successful in quitting. Nurses can be trained to deliver this treatment.

Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease which is characterized by airflow limitation that is not fully reversible [1]. Spirometry is the gold standard for the diagnosis and assessment of the disease [1]. COPD is currently the fifth leading cause of death worldwide [2], and projections for 2020 indicate further increase in global mortality, placing COPD on the third position of lethal diseases [3]. Cigarette smoking is by far the most important risk factor for COPD, and smoking cessation is the single most effective way to reduce the risk of developing COPD and to affect the outcome in patients at all stages of the disease [4], [5].

Discussing abnormal test results with smokers has been suggested as a “teachable moment” that may increase motivation to quit smoking, but there is only weak evidence to support such an approach [6]. Various studies have been performed on the efficacy of spirometry as a motivational tool for smoking cessation but their results are inconclusive [7], [8], [9]. Findings are often of limited validity because of one or more important biases such as unstandardized counselling intensity, incomparable or uncontrolled use of pharmacological aids for smoking cessation between experimental and control group, or different (or unclear) baseline levels of lung function and motivation to quit smoking [10]. A recent randomized trial clearly showed a positive effect; telling smokers their “lung age” (based on spirometry) increased the 12-month abstinence rate by 7.2%, but the mechanisms by which the intervention achieved its effect were unclear [11].

We conducted a randomized controlled trial on the efficacy of what we have termed “confrontational counselling” [12]. This is a patient-centred approach which involves confronting smokers with the consequences of their addiction (previously undiagnosed COPD) and which uses specific communication skills to identify and challenge irrational beliefs about smoking. In this article, we will use a mediation analysis to understand how exactly confrontational counselling may effect short-term abstinence from smoking (5 weeks after the target quit date). We hypothesised that confrontational counselling – through labelling with a potentially life-threatening illness status – increases risk perception and health concerns and decreases self-exempting beliefs in smokers, factors which in turn account for abstinence from smoking (see Fig. 1). Mediation analysis allows us to open up the “black box” that conceals the mechanisms of change in our intervention.

Section snippets

Methods

We used data from a randomized controlled trial comparing two active smoking cessation treatments in smokers with previously undiagnosed COPD: medium intensity confrontational counselling delivered by a respiratory nurse combined with nortriptyline for smoking cessation (experimental group) with medium intensity health education and promotion delivered by a respiratory nurse combined with nortriptyline for smoking cessation (control group). The third trial arm, “care as usual by the GP”, was

Results

A total of 116 smokers with previously undetected COPD were randomly allocated to the experimental group, 112 to the control group. The baseline characteristics are shown in Table 2. Mean baseline scores on all measures of health perceptions, quality of life, and mental health were comparable between the groups (not shown in the table), except for the subscale “physical role limitations” on the SF-36; the mean score in the experimental group was substantially higher (M = 84.1, S.D. = 30.0) than in

Discussion

We found three factors that mediated the effect of confrontational counselling on smoking cessation: self-efficacy towards successful smoking cessation, the expectation of getting a serious smoking-related disease within the next 10 years, and self-exempting beliefs towards smoking. All three mediators were independently associated with abstinence and accounted for the effect of the intervention.

The current evidence on the efficacy of spirometry as a motivational tool for smoking cessation is

Competing interest

The authors have no competing interests.

Disclosure statement

I (Daniel Kotz) confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

Acknowledgements

The authors gratefully acknowledge the contributions of Kitty van der Meer (telephonic screening, logistics), Arja van de Voorde, Ellen de Goeij (spirometry), Marleen Vaassen, Hilde Bastiaens, Rianne Romers, Tim Sales, Karin Frambach (respiratory nurses), Mischa Aussems (validation spirometric test results), Willem de Goeij (database construction), Ger Driessen and Paula Rinkens (data cleaning), Hendrikus Boersma (pharmacist), and Arnold Kester (statistical advice). Daniel Kotz is the recipient

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