Effects of Trained Health Professionals’ Behavioral Counseling Skills on Smoking Cessation Outcomes

Effects of Trained Health Professionals’ Behavioral Counseling Skills on Smoking Cessation... Abstract Background There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects. Purpose We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes. Methods Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year. Results On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers’ characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03–1.42) and 1.26 (1.05–1.50), respectively. Conclusions This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. Smoking cessation, Counseling skills, Training, Patient outcome Introduction Substantial evidence supports the provision of smoking cessation advice and counseling by health professionals to their smoker patients [1–3]. Reviews and meta-analyses have also consistently shown evidence that individual counseling from smoking cessation specialists increases the likelihood of cessation, compared to smokers receiving less intensive support [1, 2]. A recent study showed that individual practitioners differ markedly in their effectiveness, even when stationed in similar environments; differences in characteristics between practitioners accounted for 7.6% of the variance in quit rates after adjusting for smoker demographics [4]. Smoking cessation counseling training has been used to increase counseling proficiency. These training programs are effective in enhancing the counseling knowledge, skills, and confidence of health professionals and their performance of smoking cessation intervention [5–11]. Taken together, these results indicate that training health professionals to provide smoking cessation interventions has a measurable effect on point prevalence of smoking and continuous abstinence [5]. Several studies developed the methods for evaluating counseling skills for smoking cessation using simulated or standardized smokers for residents or medical students [12–16]. Of these studies, some studies show the effects of training on counseling skills using pre–post designs [12–14]. Furthermore, recent studies also identified key behavioral change techniques used in smoking cessation counseling, which are in turn associated with better quit outcomes [17, 18]. However, none of these studies quantified the relationships between counseling skills and outcomes, nor did they describe how the skills related to counseling effects. The purposes of this study were to establish a method of evaluating smoking cessation counseling skills of health professionals based on videotaped counseling sessions with a standardized smoker and examine the relationships between these skills and smoking cessation outcomes of their counseled smokers. Methods Study Design This study used data from a quasi-randomized controlled trial design for smoking cessation to examine the effects of behavioral counseling from trained health professionals at annual health checkups [19]. At six Japanese workplaces (two banks, three factories, and one college), 1,808 smokers attended their annual health checkups. The criteria for inclusion in the study were current cigarette smoker, at least 20 years of age, smoking more than one cigarette per day, and have at least 1 year of smoking history. Of the smokers, 1,733 (95.8%) consented to the intervention study. After signing informed consent forms, 900 smokers were assigned to an intervention group and 833 to a control group based on time (morning or afternoon) or day of their annual health checkup. Additionally, the study also included 25 health professionals working in the six workplaces; however, two health professionals who did not complete the training program, and counseled 42 smokers, were excluded from the study. Of the 900 smokers, data from the 858 who received individual smoking cessation counseling from 23 health professionals were included in our study. Smoking Cessation Counseling Training The health professionals in the present study were three medical doctors, eight registered nurses, and 12 public health nurses (20 women and three men; mean age, 35.9 years [range, 27–56; standard deviation {SD}, 8.15]; mean years of clinical experience 12.7 years [range, 3–33; SD, 7.45]). The health professionals received the smoking cessation counseling training; it consisted of smoking cessation counseling tailored to the smokers’ motivations to quit [20] and emphasized improvements in effective counseling techniques based on the 5As (a model that presents the five major steps [Ask, Advise, Assess, Assist, and Arrange] in providing a brief intervention in the primary care setting) and 5Rs (the content areas [Relevance, Risks, Rewards, Roadblocks, and Repetition] that should be addressed for a smoker who is unwilling to quit at this time) approaches, as recommended in the US clinical practice guidelines [1]. The program consisted of three parts conducted over 3–5 months: the first part was a 2-day basic workshop to teach basic knowledge and skills. The second part was counseling practices with two or more smokers in the health professional’s workplace, with the health professionals receiving case report feedback and videotaped practice sessions from the training lecturers. The third part was a 2-day case discussion to share experiences [21] (Fig. 1). Fig. 1. View largeDownload slide Protocol of training and evaluation. Fig. 1. View largeDownload slide Protocol of training and evaluation. Evaluation of Smoking Cessation Counseling Skills Before and after the training program, the health professionals’ skills were evaluated based on videotaped counseling sessions with a standardized smoker. The standardized smoker, who was to represent the stereotypical smoker in Japan, was a 49-year-old married male salaried employee, with children, and who was a former smoker. He received specific training to act as a typical Japanese smoker by the training program lecturers. The standardized smoker was categorized as at the “precontemplation” from the stages of a change model established by Prochaska (see below) [22], which accounts for more than half of Japanese smokers. A structured evaluation form was developed based on counseling procedures with reference to Ockene’s evaluation framework [12]. The videotapes were evaluated using this structured evaluation form which consisted of six items: (a) introduction and assessment of readiness, (b) eliciting information on cessation experiences, (c) increasing motivation for cessation, (d) building confidence for cessation, (e) identifying and reducing barriers for cessation, and (f) setting goals and arranging a follow-up schedule. All items were assessed on a Likert-type, discrete analogue scale from 0 to 4, such that the total score for the six items ranged from 0 to 24 (Table 1). Table 1 Evaluation Form for Counseling Skill Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 *Total skill scores ranges from 0 to 24. View Large Table 1 Evaluation Form for Counseling Skill Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 *Total skill scores ranges from 0 to 24. View Large Two registered nurses scored all of the videotapes independently and separately. When the scores differed, the two evaluators and an educationalist involved in the training discussed and decided on the final score together. They received videotapes at random, and were blinded to whether the videos were of pre or posttraining sessions; this status could not be inferred from the number and content of the videotapes. Both evaluators undertook the workshop teaching basic knowledge and skills and observed smoking cessation counseling by the lecturers at least 20 times. Smoking Cessation Counseling in the Intervention Study Each workplace employed 3–6 trained health professionals and between 55 and 306 smokers. At their annual health checkups, smokers received a questionnaire inquiring about sociodemographic data, the age at which they started smoking, consumption of cigarettes per day, previous experiences quitting smoking, stage of change (see below), confidence of quitting (on a 100 point scale, from “not at all” to “very”), and a Fagerstrom Test for Cigarette Dependence [23, 24]. The smoker’s stage of change was assigned by one of four categories based on Nakamura’s stage classification of Japanese smokers [25]: the immotive stage (not interested in quitting smoking and not thinking about quitting in the next 6 months); the precontemplation stage (interested in quitting smoking but not thinking about quitting in the next 6 months); the contemplation stage (planning to quit within the next 6 months); and the preparation stage (planning to quit within the next month). Smokers were tested for biomarkers using expired carbon monoxide (expired CO) and urine nicotine metabolites. Expired CO was measured using the Micro Smokerlyzer (Bedfont Scientific Ltd., Kent, UK), and urine nicotine metabolites were measured semiquantitatively using the NicCheck I Test Strips (DynaGen Inc., Cambridge, MA). Subsequently, the health professionals then handed out leaflets about the harms of smoking, nicotine dependence, and how to quit smoking, explained the test results of the biomarkers, and provided counseling to smokers. The smoking cessation counseling was conducted face-to-face on an individual basis according to the smokers’ stage of change. Each session was set to 10–20 min and composed of introduction and assessment of readiness, eliciting of information, increasing motivation, building confidence, identifying and reducing barriers, and setting goals. The 23 trained health professionals counseled, on average, 36.9 smokers (range: 1–116, SD = 29.60). However, two of the 23 health professionals counseled only one or two smokers, due to resignation or maternity leave, respectively. Subsequently, if smokers decided to set a date to start smoking cessation, the health professionals conducted follow-up via telephone calls over 3 months. For this period, the number of follow-up phone calls per subject established in the protocol was four, but the actual average follow-up frequency was 2.5 (SD = 1.88). In Japan, nicotine gum was introduced as a prescription-only item in 1994 but switched to being an over-the-counter drug in 1999; nicotine patches were introduced as prescription-only items in 2000; neither of these medications was reimbursed during the study period (1998–2000). Therefore, health professionals could not actively provide information about nicotine replacement therapy, but neither did they preclude its use. One year after counseling, we sent subjects a questionnaire via interoffice mail to assess their abstinence, start date of abstinence, and nicotine replacement therapy use. We verified abstinence by measuring expired CO. The expired CO cut-off value was 8 parts per million (ppm). Each health professional collected these data on the smokers’ characteristics and interventions. We adopted two main outcome measures: (a) the point prevalence abstinence rate, defined as not smoking for more than 1 week at the time of the 1-year follow-up survey; and (b) sustained abstinence rate, defined as not having smoked any cigarettes for the preceding 3 months or longer at the time of the 1-year follow-up survey. Statistical Analysis We used the test-retest method and interrater reliability to examine the reliability of the skills evaluation. In the test-retest method, we randomly selected 10 videotapes and evaluated them using the same method of this study. One month after the first evaluation, we reevaluated the same videotapes. We calculated the coefficients of reliability for the total and each item score. In the interrater reliability, we randomly selected 15 videotapes. Two evaluators (an educationalist involved in the training and a trained registered nurse in smoking cessation counseling) scored those videotapes independently and separately. They received videotapes at random and were blinded to whether the videos were of pre or posttraining sessions. We assessed interrater reliability with the use of interclass correlation coefficient for the total scores and the weighted kappa statistic for each item scores. Furthermore, we calculated Chronbach’s alpha to evaluate the internal consistency of the six evaluation items, using the combined data from before and after the training. We evaluated the training effects on skills with a pre–post comparison study design and used the total skill scores after training to examine the relationship between skill and intervention outcomes. We compared total skill scores, each individual item score, and counseling time before and after the training using a paired t-test. We used a regression analysis to assess the relationship between skill score before the training and after the training. Taking into account the bi-level structure of the data with smokers nested within health professionals, two-level logistic regression models with a random intercept were used to assess the association between total skill scores and setting a quit date (yes or no), and the association between total skill scores or each of the six individual evaluation scores and cessation outcomes. These were adjusted for minutes of counseling time, and characteristics of health professionals (age, years of clinical experience, job category) and smokers (sex, age, years of smoking, consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence score, expired CO, urine nicotine metabolites, confidence in quitting ability, stage of change, number of quitting experiences), with level 1 as the smoker and level 2 as the health professional. In assessing the association between those skill scores and cessation outcomes, we added further nicotine replacement therapy use and setting a quit date as adjustment factors of smokers’ characteristics. We used a simple logistic regression model for the variables: minutes of counseling time, and health professional and smoker characteristics; followed by a multiple logistic regression model to identify independent predictors. The two-level multiple logistic regression models excluded the two health professionals that only counseled 1–2 smokers each. Our data were from 1998 to 2000, smoking prevalence in Japanese males has decreased from 50.8% in 2000 to 32.2% in 2014 [26]. It was thought that the remaining smokers would be more dependent, and the proportion of dependent smokers has relatively increased since then. Therefore, we conducted similar analysis using two-level logistic regression models with a random intercept limited to middle to high dependent smokers (Fagerstrom Test for Cigarette Dependence scores of 3 or higher) to assess the association between total skill scores and cessation outcomes. Significance was set at 0.10 for entering a variable into the multiple logistic regression models and 0.05 for retention in the model. Data were analyzed using SPSS for Windows (version 22.0; IBM Corp., NY) and two-level logistic regression models were analyzed using MLwiN (version 1.1, using second-order penalized quasi-likelihood [PQL] estimation methods). Results Reliability Test for Evaluating Smoking Cessation Counseling Skills In the test-retest method, of the 10 videotapes, seven were given the same score on the first and second evaluations, and only three scores differed between evaluations. The coefficients of reliability were ρ = 0.98 (p < .001) for the total score and ρ = 0.80–1.00 (p < .01) for individual item scores. In the interrater reliability, the interclass correlation coefficient of the total score was 0.82 (p < .001). The weighted kappa statistic of each six items were (a) introduction and assessment of readiness 0.90 (p < .001), (b) eliciting information on cessation experiences 0.87 (p = .001), (c) increasing motivation for cessation 0.49 (p = .012), (d) building confidence for cessation 0.74 (p < .001), (e) identifying and reducing barriers for cessation 0.73 (p < .001), and (f) setting goals and arranging a follow-up schedule 0.66 (p = .003). The internal consistency of the six items was not high (α = 0.59), suggesting that the items are partially independent. Change in Counseling Skill Level due to Training The mean total skill scores before the training was 11.6, with a median score of 12 and a range of 7–18. The mean of each evaluation item score ranged from 1.0 to 2.9, with the item with the highest mean score being (c) increasing motivation for cessation, and that with the lowest being (a) introduction and assessment of readiness. The mean counseling time was 14.5 min (SD = 5.2) (Table 2). Table 2 Changes in Skills Scores of Trained Health Professionals Before and After Training (n = 23) Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 SD standard deviation. View Large Table 2 Changes in Skills Scores of Trained Health Professionals Before and After Training (n = 23) Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 SD standard deviation. View Large The mean total skill scores after the training was 16.1, with a median score of 16 and a range of 12–19; these values were significantly higher than those before the training (p < .001). The mean of each evaluation item score ranged from 1.3 to 3.5; all scores were significantly higher than those before the training, except for that of (b) eliciting information on cessation experiences and (c) increasing motivation for cessation. The evaluation item scores that increased more than 1 point were (d) building confidence for cessation, to 1.8; and (e) identifying and reducing barriers for cessation, to 1.0. Regression analyses revealed the association of the skill scores before training with the skill scores after the training was not significant (β= −0.345, SE = 0.183, t = −1.890, p = .073). Moreover, the mean counseling time increased to 19.0 min (SD = 3.5), significantly higher than before the training (Mean: 14.5, SD = 5.2, p < .001) (Table 2). Smoker Characteristics and Smoking Intervention Outcomes The majority of smokers were male (n = 830), with only 28 females. The mean age of the smokers was 41.9 years (range: 20–70, SD = 9.65), and the mean consumption of cigarettes per day was 20.7 (range: 1–80, SD = 9.50). The most frequently reported stage of change was precontemplation (57.1%), followed by 30.0% in immotive, 7.8% in contemplation, and 5.0% in preparation (Table 3). Table 3 Characteristics of Counseled Smokers (n = 855) Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 n number, SD standard deviation. View Large Table 3 Characteristics of Counseled Smokers (n = 855) Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 n number, SD standard deviation. View Large For smoking intervention outcomes, the mean counseling time was 15.7 min (SD = 6.0), whereas 10.7% of smokers set a quit date, and 9.7% received follow-ups. The point prevalence abstinence rate was 5.5% and sustained abstinence rate was 4.7%. Predictors of Setting a Quit Date Among Counseled Smokers To assess predictive factors of setting a quit date, the variables of minutes of counseling time, health professionals and smokers’ characteristics, and total skill scores after the training were variables in a two-level univariate logistic regression models. Five variables (urine nicotine metabolites, confidence in ability to quitting, stage of change, number of quitting experiences, and minutes of counseling time) were significant predictors of setting a quit date. The total skill scores after the training were not significant predictors (OR: 1.07, 95% CI: 0.91–1.25). Using two-level multiple logistic regression models on the five predictors, we found that “precontemplation” stage of change (OR: 4.62, 95% CI: 1.60–13.35), “contemplation” (OR: 18.25, 95% CI: 5.63–59.15), “preparation” (OR: 82.68, 95% CI: 23.91–285.91), and minutes of counseling time (OR: 1.10, 95% CI: 1.06–1.15) were significant predictors. Predictors of Abstinence Among Counseled Smokers at 1-Year Follow-Up To assess predictive factors of abstinence 1 year after the initial health checks, minutes of counseling time, and health professionals and smokers’ characteristics were variables in a univariate analysis. Nine variables (consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence score, expired CO, urine nicotine metabolites, confidence in ability to quitting, stage of change, number of quitting experiences, nicotine replacement therapy use, setting a quit date) were significant predictors of point prevalence abstinence and sustained abstinence. Using two-level multiple logistic regression models on the total skill scores after the training and nine predictors of point prevalence abstinence, we found that total skill scores after the training (OR: 1.21, 95% CI: 1.03–1.42), the “preparation” stage of change (OR: 5.85, 95% CI: 1.55–22.13) and setting a quit date (OR: 3.25, 95% CI: 1.49–7.06) were significant predictors of point prevalence. Likewise, for the total skill scores after the training and the nine factors as predictors of sustained abstinence, total skill scores after the training (OR: 1.26, 95% CI: 1.05–1.50), a stage of change of preparation (OR: 7.61, 95% CI: 1.80–32.22), and setting a quit date (OR: 3.77, 95% CI: 1.64–8.68) were significant predictors (Table 4). Table 4 Multiple Two-Level Logistic Regression Analysis With a Random Intercept for Predictors of Point Prevalence and Sustained Abstinence (n = 855) Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 CI Confidence Interval. View Large Table 4 Multiple Two-Level Logistic Regression Analysis With a Random Intercept for Predictors of Point Prevalence and Sustained Abstinence (n = 855) Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 CI Confidence Interval. View Large To assess the relationships of each of the six evaluation items with point prevalence abstinence and sustained abstinence, two-level multiple logistic regression models adjusted for the same nine predictors were used. Nine of the items were significant predictors of either point prevalence abstinence or sustained abstinence (Table 5). However, if the significance level was set at p < .10, the item of identifying and reducing barriers for cessation (OR: 1.48, 95% CI: 1.04–2.10) was a significant predictor of sustained abstinence. Table 5 Multiple Two-Level Logistic Regression Analysis With a Random Intercept to Assess the Association Between Each of the Evaluation Items and Cessation Outcomes (n = 855), Adjusted for Smoker Characteristics Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 The model was adjusted for consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence, expired carbon monoxide, urine nicotine metabolites, confidence of quitting, stage of change, number of quitting experiences, using nicotine replacement therapy, and setting a quit date. CI confidence interval. View Large Table 5 Multiple Two-Level Logistic Regression Analysis With a Random Intercept to Assess the Association Between Each of the Evaluation Items and Cessation Outcomes (n = 855), Adjusted for Smoker Characteristics Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 The model was adjusted for consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence, expired carbon monoxide, urine nicotine metabolites, confidence of quitting, stage of change, number of quitting experiences, using nicotine replacement therapy, and setting a quit date. CI confidence interval. View Large We conducted similar analyses limited to middle to high dependent smokers. Those analyses included the 646 smokers with Fagerstrom Test for Cigarette Dependence scores of 3 or higher. The two-level multiple logistic regression models testing the total skill scores after the training and the five significant predictors (confidence in ability to quitting, stage of change, nicotine replacement therapy use, years of clinical experience, and setting a quit date) as predictors of point prevalence abstinence showed that setting a quit date (OR: 3.53, 95% CI: 1.23–10.10) was a significant predictor. However, total skill scores after the training (OR: 1.19, 95% CI: 0.97–1.46) were not significant predictors. The model testing total skill scores after the training and seven significant factors (Fagerstrom Test for Cigarette Dependence score, urine nicotine metabolites, confidence in ability to quitting, stage of change, nicotine replacement therapy use, years of clinical experience, setting a quit date) as predictors of sustained abstinence showed that total skill scores after the training (OR: 1.26, 95% CI: 1.01–1.58) and setting a quit date (OR: 5.77, 95% CI: 1.89–17.62) were significant predictors. Discussion This study established a new method of skills evaluation based on videotaped counseling sessions with a standardized smoker, and examined the relationship between the skills and smoking cessation outcomes. Our study shows that higher counseling skill scores among health professionals after the training were correlated with higher smoking cessation outcomes among counseled smokers at the 1-year follow-up. These effects were statistically significant, despite the high proportion of smokers who were not ready to quit smoking. The present study is the first to examine the relationships between counseling skills and smoking cessation outcomes without the use of pharmacotherapies, and the results were similar even for analyses limited to middle to high dependent smokers. This study is also the first demonstration in the field of smoking cessation that counselling skills were predictive of counsellor success rates, providing an indication that successful counselling involves more than just nonspecific psychological support. Of clinical importance, this study provides a new tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. For alcohol use, only one study has demonstrated that counselors with better motivational interviewing skills achieved improved outcomes for reducing weekly alcohol consumption among patients after a 1-year follow-up [27]. The study used tape-recorded data from 5 counselors and 95 patients. However, the results may have been influenced by patient characteristics, given that counselors’ skill levels were evaluated during counseling sessions with patients. A more neutral evaluation can be performed by using a standardized patient for each health professional, as in the present study. The other strong predictors of abstinence were motivation to quit smoking and setting a quit date at counseling. The motivation of smokers was consistent with results from previous studies [1, 28–31]. The smokers who set a quit date at the counseling were likely to have higher motivation and receive longer counseling in this study. Furthermore, those smokers were likely to receive follow-up via telephone calls over 3 months. It was thought that higher motivation and more support led to smoking cessation. In contrast, nicotine replacement therapy use was not a significant predictor of abstinence. During the study period, nicotine gum and patches were available as prescription or over-the-counter drugs, and were not reimbursed. In this study, only 2% of smokers used nicotine gum, allowing the examination of the relationship between counseling skills and smoking cessation outcomes without the influence of pharmacotherapies. We hypothesize that systematically including pharmacotherapy as an intervention component could increase abstinence rates among counseled smokers. In the present study, total skill scores were a significant predictor of smoking abstinence; however, individual evaluation items were not significant predictors, except the item of identifying and reducing barriers for cessation with sustained abstinence (p < .10). Previous studies identified intratreatment social support and problem solving as effective components of behavioral support counseling for health professionals to use in smoking cessation counseling [1, 19, 32]. Our evaluation items included these elements. The item of identifying and reducing barriers for cessation included the elements of problem solving. The evaluation criteria as score 4 of each item were ‘eliciting and giving tailored advice and eliciting feeling.’ It was considered to be similar to intratreatment social support. Our analyses were not able to isolate individual components as significant, individual predictors of cessation outcomes, suggesting that the specific impact of each one was not sufficient to account for the predictive value of the total score. It might be that the adage of the whole being “greater than the sum of the parts” applies to this set of counseling skills, or it might be that the study did not have the statistical power to disaggregate the incremental predictive value of the components. The mean score for three of the six evaluation items after training were more than 3.0. Since scale range of each item was 0–4, a ceiling effect of skill score might explain why each item was not significant predictors. This is an area that needs further research. To quantitatively evaluate counseling skill to a standardized smoker, we used an evaluation form consisting of six items assessing details of the counseling process. The reliability of this evaluation was relatively high; we found a positive correlation between counseling skill and intervention outcome. We believe that our evaluation method can have improved current techniques for evaluating the counseling skill required for a successful smoking cessation outcome. In previous studies, smoking cessation training positively affected health professionals’ performance in motivating and helping smokers toward smoking cessation in comparison with untrained health professional controls [5–11]. The Cochrane review showed that training health professionals in smoking cessation counseling had a significant effect on point prevalence and continuous abstinence in addition to health professionals’ performance [5]. Several studies examined changes in the health professionals’ or students’ counseling skills throughout the training [12–14]. Consistent with these prior studies, the present study revealed that the counseling skill score of health professionals were significantly improved by training, particularly for enhancing confidence and reducing barriers for cessation. And, total skill scores were a significant predictor of smoking abstinence. A major limitation of our study is that its application was limited to current conditions in Japan and other countries. Smoking cessation has been greatly influenced by tobacco controls. In particular, the prevalence of smoking has decreased significantly in Western countries in recent years [33, 34]; it is believed that the remaining smokers are more dependent and, therefore, the most difficult to treat. Tobacco control in Japan has been delayed compared with Western countries, but some progress has occurred since the year 2000 in the form of passive smoking prevention, tax increases, and reimbursement for smoking cessation treatments. As a result, smoking prevalence has decreased especially among Japanese males. Our study showed that higher skill levels could also lead to better outcomes in analyses limited to middle-high dependent smokers. So, those results could be applicable to current practices. Other limitations to our study should be mentioned. First, only 23 trained health professionals were involved in the study, each counseling a variable number of smokers (1–116). Since, the odds ratios for all skill levels fell in the expected ranges, future studies examining more trained health professionals and counseled smokers may achieve more significant results. Second, we used only one standardized smoker with a single case profile to evaluate the pre and postcounseling skills of health professionals. Although there was more than 3 months between the evaluations, practice and memory effects to the same standardized smoker may have influenced the postskill scores. Third, we used data from an intervention study for smoking cessation and examined the training effect with a pre–post comparison study design [19]. We did not rigorously evaluate the training effect with a random controlled study design. In conclusion, the findings of the present study indicate that health professionals with higher behavioral skills in smoking cessation counseling can lead to better cessation outcomes. The study is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. Acknowledgements This study was supported by the Ministry of Health, Labor and Welfare (Grants-in-aid for the Third-term Comprehensive Ten-year Strategy for Cancer Control) and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus (Research on the training program for health care providers based on the standardized health guidance program and “Active guide 2013” in Japan) from Japan Agency for Medical Research and development, AMED. We thank Dr. R. West and Dr. L. Cameron for valuable comments. Compliance with Ethical Standards Conflicts of interest M. Nakamura received honoraria for lectures from a manufacture of smoking cessation products in Japan (Pfizer Japan, Inc.). As a member of Japan Medical-Dental Association for Tobacco Control, Drs. 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Effects of Trained Health Professionals’ Behavioral Counseling Skills on Smoking Cessation Outcomes

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10.1093/abm/kax049
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Abstract

Abstract Background There is evidence that training health professionals in behavioral counseling skills can lead to greater success in helping their smokers to quit. However, it is still unknown how counseling skills relate to counseling effects. Purpose We established a method of skills evaluation of health professionals for smoking cessation counseling based on videotaped counseling sessions with a standardized smoker, and examined the relationship between skill levels and smoking cessation outcomes. Methods Twenty-three health professionals at Japanese workplaces underwent a training program. Their counseling skills were evaluated before and after the program using a structured evaluation form-based analysis of videotaped interactions between participants and a standardized smoker. A total of 858 smokers then received individual smoking cessation counseling by the trained health professionals at an annual health checkup. These patients were followed-up through surveys after 1 year. Results On a scale from 0 to 24, Total skill scores, which ranged from 0 to 24, were significantly higher after the training than before the training (p < .001). Multiple two-level logistic regression analysis adjusted for smokers’ characteristics showed that the odds ratios of skill scores after the training for point prevalence and sustained abstinence rates among smokers who received counseling were 1.21 (95% confidence interval: 1.03–1.42) and 1.26 (1.05–1.50), respectively. Conclusions This study demonstrates that higher behavioral counseling skills were associated with better smoking cessation outcomes. This research is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. Smoking cessation, Counseling skills, Training, Patient outcome Introduction Substantial evidence supports the provision of smoking cessation advice and counseling by health professionals to their smoker patients [1–3]. Reviews and meta-analyses have also consistently shown evidence that individual counseling from smoking cessation specialists increases the likelihood of cessation, compared to smokers receiving less intensive support [1, 2]. A recent study showed that individual practitioners differ markedly in their effectiveness, even when stationed in similar environments; differences in characteristics between practitioners accounted for 7.6% of the variance in quit rates after adjusting for smoker demographics [4]. Smoking cessation counseling training has been used to increase counseling proficiency. These training programs are effective in enhancing the counseling knowledge, skills, and confidence of health professionals and their performance of smoking cessation intervention [5–11]. Taken together, these results indicate that training health professionals to provide smoking cessation interventions has a measurable effect on point prevalence of smoking and continuous abstinence [5]. Several studies developed the methods for evaluating counseling skills for smoking cessation using simulated or standardized smokers for residents or medical students [12–16]. Of these studies, some studies show the effects of training on counseling skills using pre–post designs [12–14]. Furthermore, recent studies also identified key behavioral change techniques used in smoking cessation counseling, which are in turn associated with better quit outcomes [17, 18]. However, none of these studies quantified the relationships between counseling skills and outcomes, nor did they describe how the skills related to counseling effects. The purposes of this study were to establish a method of evaluating smoking cessation counseling skills of health professionals based on videotaped counseling sessions with a standardized smoker and examine the relationships between these skills and smoking cessation outcomes of their counseled smokers. Methods Study Design This study used data from a quasi-randomized controlled trial design for smoking cessation to examine the effects of behavioral counseling from trained health professionals at annual health checkups [19]. At six Japanese workplaces (two banks, three factories, and one college), 1,808 smokers attended their annual health checkups. The criteria for inclusion in the study were current cigarette smoker, at least 20 years of age, smoking more than one cigarette per day, and have at least 1 year of smoking history. Of the smokers, 1,733 (95.8%) consented to the intervention study. After signing informed consent forms, 900 smokers were assigned to an intervention group and 833 to a control group based on time (morning or afternoon) or day of their annual health checkup. Additionally, the study also included 25 health professionals working in the six workplaces; however, two health professionals who did not complete the training program, and counseled 42 smokers, were excluded from the study. Of the 900 smokers, data from the 858 who received individual smoking cessation counseling from 23 health professionals were included in our study. Smoking Cessation Counseling Training The health professionals in the present study were three medical doctors, eight registered nurses, and 12 public health nurses (20 women and three men; mean age, 35.9 years [range, 27–56; standard deviation {SD}, 8.15]; mean years of clinical experience 12.7 years [range, 3–33; SD, 7.45]). The health professionals received the smoking cessation counseling training; it consisted of smoking cessation counseling tailored to the smokers’ motivations to quit [20] and emphasized improvements in effective counseling techniques based on the 5As (a model that presents the five major steps [Ask, Advise, Assess, Assist, and Arrange] in providing a brief intervention in the primary care setting) and 5Rs (the content areas [Relevance, Risks, Rewards, Roadblocks, and Repetition] that should be addressed for a smoker who is unwilling to quit at this time) approaches, as recommended in the US clinical practice guidelines [1]. The program consisted of three parts conducted over 3–5 months: the first part was a 2-day basic workshop to teach basic knowledge and skills. The second part was counseling practices with two or more smokers in the health professional’s workplace, with the health professionals receiving case report feedback and videotaped practice sessions from the training lecturers. The third part was a 2-day case discussion to share experiences [21] (Fig. 1). Fig. 1. View largeDownload slide Protocol of training and evaluation. Fig. 1. View largeDownload slide Protocol of training and evaluation. Evaluation of Smoking Cessation Counseling Skills Before and after the training program, the health professionals’ skills were evaluated based on videotaped counseling sessions with a standardized smoker. The standardized smoker, who was to represent the stereotypical smoker in Japan, was a 49-year-old married male salaried employee, with children, and who was a former smoker. He received specific training to act as a typical Japanese smoker by the training program lecturers. The standardized smoker was categorized as at the “precontemplation” from the stages of a change model established by Prochaska (see below) [22], which accounts for more than half of Japanese smokers. A structured evaluation form was developed based on counseling procedures with reference to Ockene’s evaluation framework [12]. The videotapes were evaluated using this structured evaluation form which consisted of six items: (a) introduction and assessment of readiness, (b) eliciting information on cessation experiences, (c) increasing motivation for cessation, (d) building confidence for cessation, (e) identifying and reducing barriers for cessation, and (f) setting goals and arranging a follow-up schedule. All items were assessed on a Likert-type, discrete analogue scale from 0 to 4, such that the total score for the six items ranged from 0 to 24 (Table 1). Table 1 Evaluation Form for Counseling Skill Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 *Total skill scores ranges from 0 to 24. View Large Table 1 Evaluation Form for Counseling Skill Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 Item to evaluate counseling skill and response Score Introduce and assess readiness  Not providing information 0  Provide general information on counseling 1  Provide tailored information on counseling 2  Provide tailored information on counseling and assess state of change 3  Provide tailored counseling information, assess state of change, and elicit smoker’s feelings 4 Eliciting information on cessation experiences  Not eliciting information at all 0  Confirming information just on the questionnaires 1  Providing general information on quitting experiences 2  Eliciting other information in addition to the questionnaires 3  Eliciting information and smoker’s feelings 4 Increasing motivation for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Building confidence for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Identifying and reducing barriers for cessation  Not eliciting information at all 0  Eliciting but not giving advice 1  Eliciting and giving general advice 2  Eliciting and giving tailored advice 3  Eliciting and giving tailored advice and eliciting feeling 4 Setting goal and arranging follow-up schedule  Not confirming the counseling 0  Confirming the counseling and setting general goal 1  Confirming the counseling and setting tailored goal 2  Confirming the counseling, setting tailored goal, and providing information for it 3  Confirming the counseling, setting tailored goal, and setting follow-up schedule 4 *Total skill scores ranges from 0 to 24. View Large Two registered nurses scored all of the videotapes independently and separately. When the scores differed, the two evaluators and an educationalist involved in the training discussed and decided on the final score together. They received videotapes at random, and were blinded to whether the videos were of pre or posttraining sessions; this status could not be inferred from the number and content of the videotapes. Both evaluators undertook the workshop teaching basic knowledge and skills and observed smoking cessation counseling by the lecturers at least 20 times. Smoking Cessation Counseling in the Intervention Study Each workplace employed 3–6 trained health professionals and between 55 and 306 smokers. At their annual health checkups, smokers received a questionnaire inquiring about sociodemographic data, the age at which they started smoking, consumption of cigarettes per day, previous experiences quitting smoking, stage of change (see below), confidence of quitting (on a 100 point scale, from “not at all” to “very”), and a Fagerstrom Test for Cigarette Dependence [23, 24]. The smoker’s stage of change was assigned by one of four categories based on Nakamura’s stage classification of Japanese smokers [25]: the immotive stage (not interested in quitting smoking and not thinking about quitting in the next 6 months); the precontemplation stage (interested in quitting smoking but not thinking about quitting in the next 6 months); the contemplation stage (planning to quit within the next 6 months); and the preparation stage (planning to quit within the next month). Smokers were tested for biomarkers using expired carbon monoxide (expired CO) and urine nicotine metabolites. Expired CO was measured using the Micro Smokerlyzer (Bedfont Scientific Ltd., Kent, UK), and urine nicotine metabolites were measured semiquantitatively using the NicCheck I Test Strips (DynaGen Inc., Cambridge, MA). Subsequently, the health professionals then handed out leaflets about the harms of smoking, nicotine dependence, and how to quit smoking, explained the test results of the biomarkers, and provided counseling to smokers. The smoking cessation counseling was conducted face-to-face on an individual basis according to the smokers’ stage of change. Each session was set to 10–20 min and composed of introduction and assessment of readiness, eliciting of information, increasing motivation, building confidence, identifying and reducing barriers, and setting goals. The 23 trained health professionals counseled, on average, 36.9 smokers (range: 1–116, SD = 29.60). However, two of the 23 health professionals counseled only one or two smokers, due to resignation or maternity leave, respectively. Subsequently, if smokers decided to set a date to start smoking cessation, the health professionals conducted follow-up via telephone calls over 3 months. For this period, the number of follow-up phone calls per subject established in the protocol was four, but the actual average follow-up frequency was 2.5 (SD = 1.88). In Japan, nicotine gum was introduced as a prescription-only item in 1994 but switched to being an over-the-counter drug in 1999; nicotine patches were introduced as prescription-only items in 2000; neither of these medications was reimbursed during the study period (1998–2000). Therefore, health professionals could not actively provide information about nicotine replacement therapy, but neither did they preclude its use. One year after counseling, we sent subjects a questionnaire via interoffice mail to assess their abstinence, start date of abstinence, and nicotine replacement therapy use. We verified abstinence by measuring expired CO. The expired CO cut-off value was 8 parts per million (ppm). Each health professional collected these data on the smokers’ characteristics and interventions. We adopted two main outcome measures: (a) the point prevalence abstinence rate, defined as not smoking for more than 1 week at the time of the 1-year follow-up survey; and (b) sustained abstinence rate, defined as not having smoked any cigarettes for the preceding 3 months or longer at the time of the 1-year follow-up survey. Statistical Analysis We used the test-retest method and interrater reliability to examine the reliability of the skills evaluation. In the test-retest method, we randomly selected 10 videotapes and evaluated them using the same method of this study. One month after the first evaluation, we reevaluated the same videotapes. We calculated the coefficients of reliability for the total and each item score. In the interrater reliability, we randomly selected 15 videotapes. Two evaluators (an educationalist involved in the training and a trained registered nurse in smoking cessation counseling) scored those videotapes independently and separately. They received videotapes at random and were blinded to whether the videos were of pre or posttraining sessions. We assessed interrater reliability with the use of interclass correlation coefficient for the total scores and the weighted kappa statistic for each item scores. Furthermore, we calculated Chronbach’s alpha to evaluate the internal consistency of the six evaluation items, using the combined data from before and after the training. We evaluated the training effects on skills with a pre–post comparison study design and used the total skill scores after training to examine the relationship between skill and intervention outcomes. We compared total skill scores, each individual item score, and counseling time before and after the training using a paired t-test. We used a regression analysis to assess the relationship between skill score before the training and after the training. Taking into account the bi-level structure of the data with smokers nested within health professionals, two-level logistic regression models with a random intercept were used to assess the association between total skill scores and setting a quit date (yes or no), and the association between total skill scores or each of the six individual evaluation scores and cessation outcomes. These were adjusted for minutes of counseling time, and characteristics of health professionals (age, years of clinical experience, job category) and smokers (sex, age, years of smoking, consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence score, expired CO, urine nicotine metabolites, confidence in quitting ability, stage of change, number of quitting experiences), with level 1 as the smoker and level 2 as the health professional. In assessing the association between those skill scores and cessation outcomes, we added further nicotine replacement therapy use and setting a quit date as adjustment factors of smokers’ characteristics. We used a simple logistic regression model for the variables: minutes of counseling time, and health professional and smoker characteristics; followed by a multiple logistic regression model to identify independent predictors. The two-level multiple logistic regression models excluded the two health professionals that only counseled 1–2 smokers each. Our data were from 1998 to 2000, smoking prevalence in Japanese males has decreased from 50.8% in 2000 to 32.2% in 2014 [26]. It was thought that the remaining smokers would be more dependent, and the proportion of dependent smokers has relatively increased since then. Therefore, we conducted similar analysis using two-level logistic regression models with a random intercept limited to middle to high dependent smokers (Fagerstrom Test for Cigarette Dependence scores of 3 or higher) to assess the association between total skill scores and cessation outcomes. Significance was set at 0.10 for entering a variable into the multiple logistic regression models and 0.05 for retention in the model. Data were analyzed using SPSS for Windows (version 22.0; IBM Corp., NY) and two-level logistic regression models were analyzed using MLwiN (version 1.1, using second-order penalized quasi-likelihood [PQL] estimation methods). Results Reliability Test for Evaluating Smoking Cessation Counseling Skills In the test-retest method, of the 10 videotapes, seven were given the same score on the first and second evaluations, and only three scores differed between evaluations. The coefficients of reliability were ρ = 0.98 (p < .001) for the total score and ρ = 0.80–1.00 (p < .01) for individual item scores. In the interrater reliability, the interclass correlation coefficient of the total score was 0.82 (p < .001). The weighted kappa statistic of each six items were (a) introduction and assessment of readiness 0.90 (p < .001), (b) eliciting information on cessation experiences 0.87 (p = .001), (c) increasing motivation for cessation 0.49 (p = .012), (d) building confidence for cessation 0.74 (p < .001), (e) identifying and reducing barriers for cessation 0.73 (p < .001), and (f) setting goals and arranging a follow-up schedule 0.66 (p = .003). The internal consistency of the six items was not high (α = 0.59), suggesting that the items are partially independent. Change in Counseling Skill Level due to Training The mean total skill scores before the training was 11.6, with a median score of 12 and a range of 7–18. The mean of each evaluation item score ranged from 1.0 to 2.9, with the item with the highest mean score being (c) increasing motivation for cessation, and that with the lowest being (a) introduction and assessment of readiness. The mean counseling time was 14.5 min (SD = 5.2) (Table 2). Table 2 Changes in Skills Scores of Trained Health Professionals Before and After Training (n = 23) Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 SD standard deviation. View Large Table 2 Changes in Skills Scores of Trained Health Professionals Before and After Training (n = 23) Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 Skill Scores Before the training After the training Difference between before and after Paired t-test Mean SD Mean SD Mean SD Total skill scores 11.6 2.31 16.1 2.11 4.5 3.68 p < .001 Evaluation items  Introduction and assessment of readiness 1.0 0.37 1.3 0.49 0.4 0.72 p = .016  Eliciting information on cessation experiences 2.1 0.76 2.1 0.67 0.0 1.19 p = .862  Increasing motivation for cessation 2.9 1.10 3.5 0.67 0.6 1.44 p = .055  Building confidence for cessation 1.7 1.03 3.5 0.85 1.8 1.37 p < .001  Identifying and reducing barriers for cessation 2.0 0.85 3.0 0.88 1.0 1.40 p = .003  Setting goal and arranging follow-up schedule 2.0 0.56 2.7 0.98 0.7 1.22 p = .012 Counseling time with the standardized smoker (minutes) 14.5 5.16 19.0 3.53 4.6 5.07 p < .001 SD standard deviation. View Large The mean total skill scores after the training was 16.1, with a median score of 16 and a range of 12–19; these values were significantly higher than those before the training (p < .001). The mean of each evaluation item score ranged from 1.3 to 3.5; all scores were significantly higher than those before the training, except for that of (b) eliciting information on cessation experiences and (c) increasing motivation for cessation. The evaluation item scores that increased more than 1 point were (d) building confidence for cessation, to 1.8; and (e) identifying and reducing barriers for cessation, to 1.0. Regression analyses revealed the association of the skill scores before training with the skill scores after the training was not significant (β= −0.345, SE = 0.183, t = −1.890, p = .073). Moreover, the mean counseling time increased to 19.0 min (SD = 3.5), significantly higher than before the training (Mean: 14.5, SD = 5.2, p < .001) (Table 2). Smoker Characteristics and Smoking Intervention Outcomes The majority of smokers were male (n = 830), with only 28 females. The mean age of the smokers was 41.9 years (range: 20–70, SD = 9.65), and the mean consumption of cigarettes per day was 20.7 (range: 1–80, SD = 9.50). The most frequently reported stage of change was precontemplation (57.1%), followed by 30.0% in immotive, 7.8% in contemplation, and 5.0% in preparation (Table 3). Table 3 Characteristics of Counseled Smokers (n = 855) Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 n number, SD standard deviation. View Large Table 3 Characteristics of Counseled Smokers (n = 855) Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 Characteristic Mean/n SD/% Age 41.9 9.65 Years of smoking 21.5 9.40 Consumption of cigarettes per day 20.7 9.50 Fagerstrom Test for Cigarette Dependence score (n = 5 no response) 4.0 2.22 Expired carbon monoxide (n = 4 no response) 19.1 11.57 Urine nicotine metabolites (n = 3 no response) 5.1 2.69 Confidence of quitting (n = 2 no response) 33.8 29.63 Number of quitting experiences 1.0 1.35 Sex  Men 830 96.7  Women 28 3.3 Stage of change  Immotive 258 30.1  Precontemplation 490 57.1  Contemplation 67 7.8  Preparation 43 5.0 Using nicotine replacement therapy  No 841 98.0  Yes 17 2.0 n number, SD standard deviation. View Large For smoking intervention outcomes, the mean counseling time was 15.7 min (SD = 6.0), whereas 10.7% of smokers set a quit date, and 9.7% received follow-ups. The point prevalence abstinence rate was 5.5% and sustained abstinence rate was 4.7%. Predictors of Setting a Quit Date Among Counseled Smokers To assess predictive factors of setting a quit date, the variables of minutes of counseling time, health professionals and smokers’ characteristics, and total skill scores after the training were variables in a two-level univariate logistic regression models. Five variables (urine nicotine metabolites, confidence in ability to quitting, stage of change, number of quitting experiences, and minutes of counseling time) were significant predictors of setting a quit date. The total skill scores after the training were not significant predictors (OR: 1.07, 95% CI: 0.91–1.25). Using two-level multiple logistic regression models on the five predictors, we found that “precontemplation” stage of change (OR: 4.62, 95% CI: 1.60–13.35), “contemplation” (OR: 18.25, 95% CI: 5.63–59.15), “preparation” (OR: 82.68, 95% CI: 23.91–285.91), and minutes of counseling time (OR: 1.10, 95% CI: 1.06–1.15) were significant predictors. Predictors of Abstinence Among Counseled Smokers at 1-Year Follow-Up To assess predictive factors of abstinence 1 year after the initial health checks, minutes of counseling time, and health professionals and smokers’ characteristics were variables in a univariate analysis. Nine variables (consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence score, expired CO, urine nicotine metabolites, confidence in ability to quitting, stage of change, number of quitting experiences, nicotine replacement therapy use, setting a quit date) were significant predictors of point prevalence abstinence and sustained abstinence. Using two-level multiple logistic regression models on the total skill scores after the training and nine predictors of point prevalence abstinence, we found that total skill scores after the training (OR: 1.21, 95% CI: 1.03–1.42), the “preparation” stage of change (OR: 5.85, 95% CI: 1.55–22.13) and setting a quit date (OR: 3.25, 95% CI: 1.49–7.06) were significant predictors of point prevalence. Likewise, for the total skill scores after the training and the nine factors as predictors of sustained abstinence, total skill scores after the training (OR: 1.26, 95% CI: 1.05–1.50), a stage of change of preparation (OR: 7.61, 95% CI: 1.80–32.22), and setting a quit date (OR: 3.77, 95% CI: 1.64–8.68) were significant predictors (Table 4). Table 4 Multiple Two-Level Logistic Regression Analysis With a Random Intercept for Predictors of Point Prevalence and Sustained Abstinence (n = 855) Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 CI Confidence Interval. View Large Table 4 Multiple Two-Level Logistic Regression Analysis With a Random Intercept for Predictors of Point Prevalence and Sustained Abstinence (n = 855) Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 Characteristics Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Smokers  Consumption of cigarettes per day 0.99 0.94–1.04 0.99 0.94–1.05  Fagerstrom Test for Cigarette Dependence score 0.91 0.73–1.14 0.89 0.69–1.14  Expired carbon monoxide 1.00 0.97–1.04 1.00 0.97–1.04  Urine nicotine metabolites 0.92 0.79–1.07 0.90 0.76–1.06  Confidence of quitting 1.00 0.99–1.01 1.00 0.99–1.01  Number of quitting experiences 1.08 0.87–1.34 0.99 0.78–1.26  Stage of change   Immotive 1.00 1.00   Precontemplation 2.10 0.78–5.71 2.17 0.71–6.61   Contemplation 1.49 0.35–6.30 1.42 0.28–7.32   Preparation 5.85 1.55–22.13 7.61 1.80–32.22  Using nicotine replacement therapy   No 1.00 1.00   Yes 1.84 0.42–8.04 2.07 0.45–9.41 Health professionals  Skill score after the training 1.21 1.03–1.42 1.26 1.05–1.50 Setting a quit date 3.25 1.49–7.06 3.77 1.64–8.68 CI Confidence Interval. View Large To assess the relationships of each of the six evaluation items with point prevalence abstinence and sustained abstinence, two-level multiple logistic regression models adjusted for the same nine predictors were used. Nine of the items were significant predictors of either point prevalence abstinence or sustained abstinence (Table 5). However, if the significance level was set at p < .10, the item of identifying and reducing barriers for cessation (OR: 1.48, 95% CI: 1.04–2.10) was a significant predictor of sustained abstinence. Table 5 Multiple Two-Level Logistic Regression Analysis With a Random Intercept to Assess the Association Between Each of the Evaluation Items and Cessation Outcomes (n = 855), Adjusted for Smoker Characteristics Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 The model was adjusted for consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence, expired carbon monoxide, urine nicotine metabolites, confidence of quitting, stage of change, number of quitting experiences, using nicotine replacement therapy, and setting a quit date. CI confidence interval. View Large Table 5 Multiple Two-Level Logistic Regression Analysis With a Random Intercept to Assess the Association Between Each of the Evaluation Items and Cessation Outcomes (n = 855), Adjusted for Smoker Characteristics Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 Each of the evaluation items Point prevalence abstinence Sustained abstinence Odds ratio 95% CI Odds ratio 95% CI Introduction and assessment of readiness 1.32 0.70–2.47 1.73 0.87–3.43 Eliciting information on cessation experiences 1.42 0.89–2.26 1.41 0.84–2.35 Increasing motivation for cessation 1.11 0.60–2.06 1.02 0.51–2.01 Building confidence for cessation 1.28 0.75–2.20 1.25 0.69–2.25 Identifying and reducing barriers for cessation 1.33 0.91–1.94 1.48 0.97–2.25 Setting goal and arranging follow-up schedule 1.27 0.91–1.77 1.34 0.93–1.94 The model was adjusted for consumption of cigarettes per day, Fagerstrom Test for Cigarette Dependence, expired carbon monoxide, urine nicotine metabolites, confidence of quitting, stage of change, number of quitting experiences, using nicotine replacement therapy, and setting a quit date. CI confidence interval. View Large We conducted similar analyses limited to middle to high dependent smokers. Those analyses included the 646 smokers with Fagerstrom Test for Cigarette Dependence scores of 3 or higher. The two-level multiple logistic regression models testing the total skill scores after the training and the five significant predictors (confidence in ability to quitting, stage of change, nicotine replacement therapy use, years of clinical experience, and setting a quit date) as predictors of point prevalence abstinence showed that setting a quit date (OR: 3.53, 95% CI: 1.23–10.10) was a significant predictor. However, total skill scores after the training (OR: 1.19, 95% CI: 0.97–1.46) were not significant predictors. The model testing total skill scores after the training and seven significant factors (Fagerstrom Test for Cigarette Dependence score, urine nicotine metabolites, confidence in ability to quitting, stage of change, nicotine replacement therapy use, years of clinical experience, setting a quit date) as predictors of sustained abstinence showed that total skill scores after the training (OR: 1.26, 95% CI: 1.01–1.58) and setting a quit date (OR: 5.77, 95% CI: 1.89–17.62) were significant predictors. Discussion This study established a new method of skills evaluation based on videotaped counseling sessions with a standardized smoker, and examined the relationship between the skills and smoking cessation outcomes. Our study shows that higher counseling skill scores among health professionals after the training were correlated with higher smoking cessation outcomes among counseled smokers at the 1-year follow-up. These effects were statistically significant, despite the high proportion of smokers who were not ready to quit smoking. The present study is the first to examine the relationships between counseling skills and smoking cessation outcomes without the use of pharmacotherapies, and the results were similar even for analyses limited to middle to high dependent smokers. This study is also the first demonstration in the field of smoking cessation that counselling skills were predictive of counsellor success rates, providing an indication that successful counselling involves more than just nonspecific psychological support. Of clinical importance, this study provides a new tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. For alcohol use, only one study has demonstrated that counselors with better motivational interviewing skills achieved improved outcomes for reducing weekly alcohol consumption among patients after a 1-year follow-up [27]. The study used tape-recorded data from 5 counselors and 95 patients. However, the results may have been influenced by patient characteristics, given that counselors’ skill levels were evaluated during counseling sessions with patients. A more neutral evaluation can be performed by using a standardized patient for each health professional, as in the present study. The other strong predictors of abstinence were motivation to quit smoking and setting a quit date at counseling. The motivation of smokers was consistent with results from previous studies [1, 28–31]. The smokers who set a quit date at the counseling were likely to have higher motivation and receive longer counseling in this study. Furthermore, those smokers were likely to receive follow-up via telephone calls over 3 months. It was thought that higher motivation and more support led to smoking cessation. In contrast, nicotine replacement therapy use was not a significant predictor of abstinence. During the study period, nicotine gum and patches were available as prescription or over-the-counter drugs, and were not reimbursed. In this study, only 2% of smokers used nicotine gum, allowing the examination of the relationship between counseling skills and smoking cessation outcomes without the influence of pharmacotherapies. We hypothesize that systematically including pharmacotherapy as an intervention component could increase abstinence rates among counseled smokers. In the present study, total skill scores were a significant predictor of smoking abstinence; however, individual evaluation items were not significant predictors, except the item of identifying and reducing barriers for cessation with sustained abstinence (p < .10). Previous studies identified intratreatment social support and problem solving as effective components of behavioral support counseling for health professionals to use in smoking cessation counseling [1, 19, 32]. Our evaluation items included these elements. The item of identifying and reducing barriers for cessation included the elements of problem solving. The evaluation criteria as score 4 of each item were ‘eliciting and giving tailored advice and eliciting feeling.’ It was considered to be similar to intratreatment social support. Our analyses were not able to isolate individual components as significant, individual predictors of cessation outcomes, suggesting that the specific impact of each one was not sufficient to account for the predictive value of the total score. It might be that the adage of the whole being “greater than the sum of the parts” applies to this set of counseling skills, or it might be that the study did not have the statistical power to disaggregate the incremental predictive value of the components. The mean score for three of the six evaluation items after training were more than 3.0. Since scale range of each item was 0–4, a ceiling effect of skill score might explain why each item was not significant predictors. This is an area that needs further research. To quantitatively evaluate counseling skill to a standardized smoker, we used an evaluation form consisting of six items assessing details of the counseling process. The reliability of this evaluation was relatively high; we found a positive correlation between counseling skill and intervention outcome. We believe that our evaluation method can have improved current techniques for evaluating the counseling skill required for a successful smoking cessation outcome. In previous studies, smoking cessation training positively affected health professionals’ performance in motivating and helping smokers toward smoking cessation in comparison with untrained health professional controls [5–11]. The Cochrane review showed that training health professionals in smoking cessation counseling had a significant effect on point prevalence and continuous abstinence in addition to health professionals’ performance [5]. Several studies examined changes in the health professionals’ or students’ counseling skills throughout the training [12–14]. Consistent with these prior studies, the present study revealed that the counseling skill score of health professionals were significantly improved by training, particularly for enhancing confidence and reducing barriers for cessation. And, total skill scores were a significant predictor of smoking abstinence. A major limitation of our study is that its application was limited to current conditions in Japan and other countries. Smoking cessation has been greatly influenced by tobacco controls. In particular, the prevalence of smoking has decreased significantly in Western countries in recent years [33, 34]; it is believed that the remaining smokers are more dependent and, therefore, the most difficult to treat. Tobacco control in Japan has been delayed compared with Western countries, but some progress has occurred since the year 2000 in the form of passive smoking prevention, tax increases, and reimbursement for smoking cessation treatments. As a result, smoking prevalence has decreased especially among Japanese males. Our study showed that higher skill levels could also lead to better outcomes in analyses limited to middle-high dependent smokers. So, those results could be applicable to current practices. Other limitations to our study should be mentioned. First, only 23 trained health professionals were involved in the study, each counseling a variable number of smokers (1–116). Since, the odds ratios for all skill levels fell in the expected ranges, future studies examining more trained health professionals and counseled smokers may achieve more significant results. Second, we used only one standardized smoker with a single case profile to evaluate the pre and postcounseling skills of health professionals. Although there was more than 3 months between the evaluations, practice and memory effects to the same standardized smoker may have influenced the postskill scores. Third, we used data from an intervention study for smoking cessation and examined the training effect with a pre–post comparison study design [19]. We did not rigorously evaluate the training effect with a random controlled study design. In conclusion, the findings of the present study indicate that health professionals with higher behavioral skills in smoking cessation counseling can lead to better cessation outcomes. The study is of clinical importance in that it provides a tool for assessing counselling skills in a way that is demonstrably relevant to outcomes. Acknowledgements This study was supported by the Ministry of Health, Labor and Welfare (Grants-in-aid for the Third-term Comprehensive Ten-year Strategy for Cancer Control) and the Practical Research Project for Life-Style related Diseases including Cardiovascular Diseases and Diabetes Mellitus (Research on the training program for health care providers based on the standardized health guidance program and “Active guide 2013” in Japan) from Japan Agency for Medical Research and development, AMED. We thank Dr. R. West and Dr. L. Cameron for valuable comments. Compliance with Ethical Standards Conflicts of interest M. Nakamura received honoraria for lectures from a manufacture of smoking cessation products in Japan (Pfizer Japan, Inc.). As a member of Japan Medical-Dental Association for Tobacco Control, Drs. 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Annals of Behavioral MedicineOxford University Press

Published: Sep 1, 2018

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