- •Principles of MI in tobacco cessation counseling may benefit from increased personalization.
- •We identify behavioral indicators of engagement in telephone counseling for tobacco cessation.
- •Those with psychiatric symptoms may have different engagement practices and needs during tobacco cessation treatment.
Though telephone counseling is a modality commonly used to promote health behavior change, including tobacco cessation, specific counselor and participant behaviors that indicate engagement and therapeutic alliance remain poorly characterized in the literature. We sought to explore smokers' and counselors' engagement and rapport-building behaviors in telephone counseling for smoking cessation and patterns of these behaviors by smokers' psychiatric symptoms.
The study team transcribed, audio-recorded tobacco cessation counseling calls for the presence of engagement and rapport-building behaviors among recently hospitalized participants enrolled in a smoking cessation randomized controlled trial (RCT). The study used baseline data from the RCT to explore frequencies of counselors' and smokers' behaviors among smokers who had reported more (vs. fewer) symptoms of depression (PHQ8 ≥ 10) or anxiety (GAD7 ≥ 10) at study entry.
Participants (n = 37) were mostly female (23/37), White (26/37), with a median age of 58. At study entry while hospitalized, moderate-to-severe symptoms of depression (18/37) and anxiety (22/37) were common. Participant-led engagement behaviors included referencing past quit attempts, asking questions, elaborating response to yes/no questions, expressing commitment to behavior change, and assigning importance to nonautomated calls. Counselor-led behaviors included building off prior interaction, empathy, normalizing challenges, reframing and summarizing, validating achievements, and expressing shared experience. Both participants and counselors engaged via general discussion and humor. Participant-led engagement behaviors appeared more often in call transcripts among patients with higher baseline depression and anxiety symptoms compared to those with lower symptom scores.
This study classified participant-led, counselor-led, and shared engagement behaviors during tobacco cessation counseling calls. Increased engagement via telephone counseling may be important for individuals with psychiatric symptoms identified at the start of treatment.
Though U.S. Public Health Service practice guidelines state that tobacco cessation counseling combined with FDA-approved medication is the standard-of-care for tobacco treatment (
Fiore et al., 2008), less than 10% of individuals trying to quit smoking use counseling (
- Fiore M.C.
- Jaén C.R.
- Baker T.B.
- Bailey W.C.
- Benowitz N.L.
- Curry S.J.
- Healton C.G.
Treating tobacco use and dependence: 2008 update.
US Department of Health and Human Services, Rockville, MD2008
Babb et al., 2017). A recent Cochrane review of 104 trials determined that telephone counseling increases rates of tobacco cessation, particularly among individuals receiving multiple contacts (
- Babb S.
- Malarcher A.
- Schauer G.
- Asman K.
- Jamal A.
Quitting smoking among adults—United States, 2000–2015.
Morbidity and Mortality Weekly Report. 2017; 65: 1457-1464
Matkin et al., 2019). Formation of an early therapeutic relationship predicts ongoing engagement throughout treatment and retention in substance use programming (
- Matkin W.
- Ordóñez-Mena J.M.
- Hartmann-Boyce J.
Telephone counselling for smoking cessation.
Cochrane Database of Systematic Reviews. 2019;
Meier et al., 2005). People with depression and anxiety smoke at higher rates and tend to have more difficulty quitting than members of the general population (
- Meier P.S.
- Barrowclough C.
- Donmall M.C.
The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature.
Addiction. 2005; 100: 304-316https://doi.org/10.1111/j.1360-0443.2004.00935.x
Fluharty et al., 2017;
- Fluharty M.
- Taylor A.E.
- Grabski M.
- Munafo M.R.
The association of cigarette smoking with depression and anxiety: A systematic review.
Nicotine & Tobacco Research. 2017; 19: 3-13https://doi.org/10.1093/ntr/ntw140
Mathew et al., 2017;
- Mathew A.R.
- Hogarth L.
- Leventhal A.M.
- Cook J.W.
- Hitsman B.
Cigarette smoking and depression comorbidity: Systematic review and proposed theoretical model.
Addiction. 2017; 112: 401-412
Piper et al., 2011;
- Piper M.E.
- Cook J.W.
- Schlam T.R.
- Jorenby D.E.
- Baker T.B.
Anxiety diagnoses in smokers seeking cessation treatment: Relations with tobacco dependence, withdrawal, outcome and response to treatment.
Addiction. 2011; 106: 418-427https://doi.org/10.1111/j.1360-0443.2010.03173.x
Weinberger et al., 2020), suggesting increased need for strategies to engage these smokers in cessation treatment. Understanding behaviors that indicate counselor and participant engagement during smoking cessation counseling may facilitate interventions aimed at increasing engagement, especially among people with depression and anxiety.
- Weinberger A.H.
- Chaiton M.O.
- Zhu J.
- Wall M.M.
- Hasin D.S.
- Goodwin R.D.
Trends in the prevalence of current, daily, and nondaily cigarette smoking and quit ratios by depression status in the US: 2005–2017.
American Journal of Preventive Medicine. 2020; 58: 691-698
Motivational interviewing (MI) focuses on strengthening participants' commitment to behavior change, increasing motivation, and reducing ambivalence (
Miller and Rollnick, 2012). Use of MI for smoking cessation is widespread, though a 2019 Cochrane review of 37 studies and 15,000 included individuals noted insufficient evidence to demonstrate efficacy of MI for smoking cessation (
- Miller W.R.
- Rollnick S.
Motivational interviewing: Helping people change.
Guilford press, 2012
Lai et al., 2010). The review noted issues in study design, outcomes, sparsity of data, bias, and heterogeneous delivery of MI limiting study quality and interpretation (
- Lai D.T.
- Cahill K.
- Qin Y.
- Tang J.L.
Motivational interviewing for smoking cessation.
Cochrane Database of Systematic Reviews. 2010;
Lai et al., 2010). Despite limitations in our understanding of MI efficacy, an MI-consistent approach to smoking cessation treatment by therapists is positively associated with observers' ratings of working alliance and participant engagement in counseling sessions (
- Lai D.T.
- Cahill K.
- Qin Y.
- Tang J.L.
Motivational interviewing for smoking cessation.
Cochrane Database of Systematic Reviews. 2010;
Boardman et al., 2006), offering insight into behaviors that are consistent with high-quality engagement and downstream cessation. However, specific counselor and participant behaviors that indicate engagement and therapeutic alliance and their evolution over the course of the therapeutic relationship remain poorly characterized. Furthermore, MI can improve symptoms of both substance use disorder and comorbid depression and anxiety (
- Boardman T.
- Catley D.
- Grobe J.E.
- Little T.D.
- Ahluwalia J.S.
Using motivational interviewing with smokers: Do therapist behaviors relate to engagement and therapeutic alliance?.
Journal of Substance Abuse Treatment. 2006; 31: 329-339
Baker et al., 2012;
- Baker A.L.
- Thornton L.K.
- Hiles S.
- Hides L.
- Lubman D.I.
Psychological interventions for alcohol misuse among people with co-occurring depression or anxiety disorders: A systematic review.
Journal of Affective Disorders. 2012; 139: 217-229
Brown et al., 2009). Individuals who smoke tobacco and have comorbid depression and anxiety may enact or elicit different engagement behaviors during counseling (
- Brown R.A.
- Strong D.R.
- Abrantes A.M.
- Myers M.G.
- Ramsey S.E.
- Kahler C.W.
Effects on substance use outcomes in adolescents receiving motivational interviewing for smoking cessation during psychiatric hospitalization.
Addictive Behaviors. 2009; 34: 887-891
Hall et al., 1996;
- Hall J.A.
- Roter D.L.
- Milburn M.A.
- Daltroy L.H.
Patients' health as a predictor of physician and patient behavior in medical visits: A synthesis of four studies.
Medical Care. 1996; : 1205-1218
Jonassaint et al., 2013;
- Jonassaint C.R.
- Haywood Jr., C.
- Korthuis P.T.
- Cooper L.A.
- Saha S.
- Sharp V.
- Beach M.C.
The impact of depressive symptoms on patient–provider communication in HIV care.
AIDS Care. 2013; 25: 1185-1192
Swenson et al., 2008). Understanding whether and how communication styles differ among this group at higher risk of persistent smoking is an important step toward personalizing care to maximize its effectiveness.
- Swenson S.L.
- Rose M.
- Vittinghoff E.
- Stewart A.
- Schillinger D.
The influence of depressive symptoms on clinician-patient communication among patients with type 2 diabetes.
Medical Care. 2008; : 257-265
In this study, we define participant engagement as behaviors that indicate smokers' active involvement in the smoking cessation counseling call. The study defines counselors' engagement behaviors as the strategies used by counselors to promote patient engagement in counseling. These behaviors often reflect how MI skills and techniques manifest in counselors' behavior. We use qualitative analysis of transcribed smoking cessation telephone counseling calls to characterize participants' behaviors, indicating their engagement during counseling and counselors' behaviors promoting patients' engagement. We also explore frequencies of counselors' and participants' engagement behaviors for participants with differing psychological profiles by using patient self-reported depression and anxiety symptoms at study baseline. Our objective was to use qualitative methods to identify patterns of behavior and generate hypotheses about effective telephone counseling.
2.1 Participants and procedures
This study was embedded within a parent trial, Helping HAND 4 (HH4 NCT03603496), a two-arm randomized control trial conducted across three sites (Massachusetts General Hospital [MGH], University of Pittsburgh Medical Center [UMPC], Vanderbilt University Medical Center [VUMC]). The trial tests the effectiveness of Personalized Tobacco Care Management (PTCM), which provides nicotine replacement therapy (NRT) and smoking cessation support from a certified tobacco treatment specialist (CTTS), versus eReferral to a state Quitline, for producing validated tobacco abstinence six months post-hospital discharge. Study staff identified eligible adults admitted at one of the three study hospitals, noted in the electronic health record as daily tobacco users, who expressed willingness to try to quit smoking after discharge and take home a prescription for NRT. The study obtained ethical approval from the IRBs of all participating institutions. All participants provided verbal informed consent for their recorded calls to be analyzed.
The full trial protocol is available for reference (
Rigotti et al., 2020). Of relevance to this study, a baseline survey during index hospitalization assessed participants' sociodemographic characteristics, smoking history, and psychosocial factors. An automated communication platform contacted participants in the PTCM arm seven times post-hospital discharge. Specific patient responses during the automated call triggered a callback from a hospital-based CTTS (i.e., smoking or difficulty with medication); participants could also request a return call from a CTTS during the automated call. CTTS calls included standardized assessment of current smoking status, medication use, and withdrawal symptoms, along with tailored brief counseling interventions, an adaptation of MI, and modules related to tobacco medication, withdrawal symptoms, cravings, stress, relapses, assistance around quit attempts, self-care, and improving confidence. Sites selected a random sample (5%) of CTTS counseling calls (total n = 1250) for fidelity monitoring, performed through real-time evaluation or recorded for subsequent review, depending on monitor availability. The study modeled the counseling strategy using MI principals and conducted fidelity monitoring using the Motivational Interviewing Treatment Integrity (MITI) Coding Manual (
- Rigotti N.A.
- Schnitzer K.
- Davis E.M.
- Regan S.
- Chang Y.
- Kelley J.H.
- Levy D.E.
Comparative effectiveness of post-discharge strategies for hospitalized smokers: Study protocol for the helping HAND 4 randomized controlled trial.
Trials. 2020; 21: 1-12
Moyers et al., 2016). Ten CTTS (9 female, 1 male) provided telephone counseling during the study (MGH n = 5, UPMC n = 2, VUMC n = 3). All counselors completed Tobacco Treatment Specialist Training at an institution accredited by the Council for Tobacco Treatment Training Programs with a 3–5 day in-person component and passed a required certification examination. CTTS did not access participant baseline depression and anxiety scores prior to initiating counseling calls.
- Moyers T.B.
- Rowell L.N.
- Manuel J.K.
- Ernst D.
- Houck J.M.
The motivational interviewing treatment integrity code (MITI 4): Rationale, preliminary reliability and validity.
Journal of Substance Abuse Treatment. 2016; 65: 36-42
This qualitative study used a random sample of recorded counseling calls from 4/12/19 to 7/12/19 for transcription, coding, and analysis (n = 37). This study did not use calls that were evaluated in real-time as they were not recorded. Participants directly requested 9/37 (26%) of the calls in our randomly selected sample, compared to 276/1250 (22%) of all study calls. The research team based qualitative sample size on saturation of major themes (
Corbin and Strauss, 2014). Average call duration was 9 min and 2 s (SD = 5.61 min, range 2.27–21.5).
- Corbin J.
- Strauss A.
Basics of qualitative research: Techniques and procedures for developing grounded theory.
Sage publications, 2014
2.2 Quantitative measures
Participant responses to the baseline survey informed demographic characteristics (age, sex, race, education) and nicotine dependence (calculated via the Heaviness of Smoking Index, HSI) (
Heatherton et al., 1991). The Generalized Anxiety Disorder 7-item scale assessed baseline symptoms of anxiety, with moderate-severe scores defined as ≥10 (
- Heatherton T.F.
- Kozlowski L.T.
- Frecker R.C.
- Fagerström K.-O.
The Fagerström test for nicotine dependence: A revision of the Fagerström tolerance questionnaire.
British Journal of Addiction. 1991; 86: 1119-1127https://doi.org/10.1111/j.1360-0443.1991.tb01879.x
Spitzer et al., 2006). The Patient Health Questionnaire 8-item scale assessed baseline symptoms of depression, with moderate-severe scores defined as ≥10 (
- Spitzer R.L.
- Kroenke K.
- Williams J.B.
- Löwe B.
A brief measure for assessing generalized anxiety disorder: The GAD-7.
Archives of Internal Medicine. 2006; 166: 1092-1097https://doi.org/10.1001/archinte.166.10.1092
Kroenke et al., 2009).
- Kroenke K.
- Strine T.W.
- Spitzer R.L.
- Williams J.B.
- Berry J.T.
- Mokdad A.H.
The PHQ-8 as a measure of current depression in the general population.
Journal of Affective Disorders. 2009; 114: 163-173https://doi.org/10.1016/j.jad.2008.06.026
2.3 Qualitative analysis
Qualitative analyses utilized verbatim transcriptions of counseling recordings with NVivo qualitative software version 12.0 (QSR International Pty. Ltd., 2012, Australia). A team of three investigators with backgrounds in medicine (GK), psychiatry (KS), and psychology (NS) completed data coding and analysis. The team jointly reviewed transcripts to develop an initial codebook of nodes and definitions corresponding to domains emerging from the counseling calls. All three investigators jointly reviewed the first six (15%) transcripts to refine code definitions, then two of the three investigators coded the next 10 (23%) transcripts. The team compared codes applied to these double-coded transcripts across coders and discussed disagreements until they reached consensus around all codes, as demonstrated by a high level of intercoder agreement (kappa >0.8). The three coders applied the final codebook to the remaining transcripts, coding at the passage level (i.e., continuous speech by one speaker).
Further analysis compared engagement behaviors across participants with high (vs. low) baseline symptoms of anxiety and depression and employed coding matrices (
Saldaña, 2009) to compare the frequency of passages (continuous speech by one speaker) coded with each theme between groups.
- Saldaña J.
The coding manual for qualitative researchers.
Procedural measures to promote rigor (
Mays and Pope, 2000) included analysis by individuals with different research backgrounds to limit introduction of personal biases, weekly meetings to discuss data and develop consensus, and documentation of coding and analytic procedures. The team compared results with established motivational interviewing concepts and generated hypotheses regarding potential for findings to impact practice.
- Mays N.
- Pope C.
Qualitative research in health care.Assessing quality in qualitative research.
. 2000; 320: 50-52https://doi.org/10.1136/bmj.320.7226.50
3.1 Participant characteristics
Participants (N = 37) were mostly female (23/37), White (26/37), with a median age of 58 and low nicotine dependence (23/37). Moderate-to-severe symptoms of depression (18/37) and anxiety (22/37) were common at study entry while hospitalized (Table 1).
Table 1Participant characteristics.
|N (%) (N = 37)|
|Massachusetts General Hospital||16 (43)|
|University of Pittsburgh Medical Center||12 (32)|
|Vanderbilt University Medical Center||9 (24)|
|Age (median, IQR)||58 [50, 63]|
|Female sex||23 (62)|
|<High school||7 (19)|
|High school graduate or GED||15 (41)|
|Some college||12 (32)|
|College graduate or higher||3 (8)|
|Low (0–2)||23 (62)|
|Moderate (3–4)||13 (35)|
|High (5–6)||1 (3)|
|Mild (<10)||14 (38)|
|Moderate (10–15)||11 (30)|
|Severe (>15)||11 (30)|
|Mild (<10)||18 (49)|
|Moderate (10–15)||12 (32)|
|Severe (>15)||6 (16)|
a Measured via the Heaviness of Smoking Index (HSI) based on time to first cigarette and number of cigarettes per day; assessed at baseline in hospital.
b Measured via Generalized Anxiety Disorder (GAD-7) scale, assessed at baseline in hospital.
c Measured via Patient Health Questionnaire (PHQ-8) scale, assessed at baseline in hospital.
3.2 Engagement behaviors in counseling calls
3.2.1 Participant-driven engagement behaviors
18.104.22.168 Referencing past quit attempts
One way that participants tended to engage with the counselor (Table 2) was referring to past quit strategies and offering context, including past triggers or programs utilized. This process was participant-driven but mirrors a similar technique commonly used by MI counselors, termed “Looking Back,” where a counselor encourages a participant to scan past events for relevance to the current scenario (
- Anstiss T.
Motivational interviewing in primary care.
Journal of Clinical Psychology in Medical Settings. 2009; 16: 87-93https://doi.org/10.1007/s10880-009-9155-x
I'm just going to chew my gum because there's one thing y'all said …that you find that you need it more than just a month. And that's what they were doing with that [state] program that was here last year that I quit. But as soon as the program was over, the 30 days, I relapsed and went back to smoking. So you're saying, “Three months.” So I said, “I'm going to hang to see if there is some truth to this.” I think there is.- Female, PA
Table 2Engagement behaviors in counseling calls.
|Referencing past quit attempts|
offered in relation to current attempt
|Building off prior connection|
reference to previous study interactions
not related to tobacco
seeking clarification from counselor
toward participant or circumstance
shared joke or laughter
unprompted expansion of responses
emphasis on commonality of experience
statements of commitment to positive behavior change
|Reframing and summarizing|
interpretation of participant statement and/or call content
|Expressing the importance of “live calls”|
statements of appreciation for human interactions in the intervention
|Affirmation and validation|
recognition of accomplishment
22.214.171.124 Asking questions
Participants engaged with their counselors by asking questions and requesting information, filling critical knowledge gaps that may present significant barriers to successful quit attempts. These offered counselors the opportunity to provide new information and correct misinformation.
Oh, so I can't have a heart attack doing that [smoking while wearing the nicotine patch]? Because that's what everybody says.- Female, PA
Rhetorical questions provided opportunities for counselors to meet participants' relational needs by engaging in active listening.
And it's sort of a dilemma, like why am I even taking a drag of a cigarette? I can't answer that question, you know?- Male, MA
Participants demonstrated investment in the counseling conversation by expanding their responses to counselors' questions beyond what was directly asked, often adding context to close-ended questions.
CTTS: And have you been using the 14-milligram patch and the 2-milligram lozenge?
PT: I'm using the lozenges only because I'm trying to hold off on the patches. The glue adhesive will irritate my skin …I got everything that you sent and the stuff from the pharmacy, so I have them if I need them. But right now just the lozenges and it's working well.- Female, MA
126.96.36.199 Change talk
Participants engaging in “change talk” clearly indicated their intentions to change future behavior. For example, some participants recalled their decisions to quit smoking, committed to trying a new strategy to manage cravings, or expressed an intention to start smoking cessation medication. Though counselors frequently encouraged patient-generated, change talk, they also worked to guide the discussion in this direction.
Well, I am so glad that I've spoken with you. And yes, I will go to the 14-milligram patch and be wearing it. Because I actually did have more energy when I was using the patch, I think.- Female, MA
188.8.131.52 Expressing the importance of “live calls”
Often toward the end of counseling calls, participants expressed gratitude to the counselor, describing their appreciation for the opportunity to speak with someone in person. “It was nice to talk to a…live person, finally” (Male, MA). Participants seemed to appreciate the idea that someone was checking in on them and invested in their success in quitting, “I appreciate your call. I appreciate that information on the lozenges. I didn't know you could take them like that.” (Male, TN). One participant, nervous about potential upcoming triggers, offered “If you want to call me next week, see how I made out this weekend.” (Male, MA).
3.2.2 Counselor-driven engagement behaviors
184.108.40.206 Building off prior connection
Counselors sometimes referenced past experiences with individual participants, demonstrating recollection of past conversations and situating counseling calls in the context of a broader counselor-participant relationship.
I remember talking to you in the hospital when you were here, and I really felt like you were one of those people who were determined to quit, and if you were determined to quit, you were going to do it…so I have to say congratulations to you, because you are doing it.- Counselor speaking to Male, MA
Counselors engaged in empathy when they identified, recognized, or validated participants' feelings and emotions, such as validating the challenges participants faced in the post-hospital context or concerns of medication safety. Often, use of empathy required some reflection of participants' statements with recommendations.
Right, like I said, the studies have shown that it is safe, but I understand your concern, and I would definitely recommend talking to your cardiologist if that will make you feel better about it.- Counselor speaking to Female, PA
Counselors emphasized that difficulties participants encountered were common among those trying to quit.
Okay, that's definitely understandable. Stress, and being upset, and all that, it's definitely very normal to get cravings during that time, and that's really good that you've been using your lozenges. That's perfect. It's a perfect time to use them.- Counselor speaking to Female, TN
220.127.116.11 Reframing and summarizing
Counselors frequently summarized and reflected what they believed the participant had said.
You're definitely taking the first step…you said you cleaned out your car, and then you got a new car because you know that that's a trigger, smoking in the car. And you're recognizing that stress is a trigger and then certain times during your workday. So those are all the first steps to recognizing when you're going to have those cravings.- Counselor speaking to Female, PA
Summary and reflection sometimes included reframing, often in a positive light, information that the participant had conveyed. For example, framing a moderate level of confidence in quitting (5 out of 10) in a positive light, or physical changes as a direct result of smoking reduction.
So that's because you're smoking less. That's probably the feeling that you have is that you don't have that bronchial constriction from so many cigarettes. You'll feel even better if you can get these last 10 to 15 gone, too.- Counselor speaking to Female, MA
18.104.22.168 Affirmation and validation
Counselors often expressed congratulations and encouragement to continue making positive change when participants expressed an accomplishment such as smoking cessation, reduction, or successful use of a medication or strategy.
That's great… So you've come a long way in a short time. You're at a quarter of a pack. So you're getting really close. What do you think might be the easiest cigarettes that you could potentially focus on to get rid of?- Counselor speaking to Female, TN
22.214.171.124 Shared experience
Discussion of shared experiences was a less common engagement behavior. Counselors sometimes disclosed their own personal experiences with quitting smoking when it was similar to participants' experiences.
I can tell you that when I was quitting smoking I could be at work the whole day and have not even one minor craving until I went to my car and opened the door and it would almost knock me over…I could work twelve hours, sixteen hours, or two hours. It just didn't matter, when I opened the door, that's the way it is.- Counselor speaking to Male, MA
In other instances, counselors shared experiences unrelated to smoking.
PT: Yeah, because you know how it is nowadays. You get robocalls all day long.
CTTS: I know. I get them all the time…It's the worst. And then there is no way to stop them. It just always happens.- Male, TN
3.2.3 Engagement behaviors of both participants and counselors
126.96.36.199 General discussion
At times during counseling calls, conversation shifted away from topic of smoking. Both counselors and smokers initiated these non–smoking related discussions.
CTTS: But as far as the house goes…you were looking for a new house, and I know that was one of the things that was causing some stress.
PT: Yeah. That's still a problem.
CTTS: So where is that at?- Female, MA
PT: See, I have these cataracts on both my eyes…next Monday, I go in and he's going to take it off the left eye, and [later] they'll take that off the right eye. And I'm hoping…I'm gonna have a big blowout or something.- Female, TN
Humor was another behavior that both counselors and participants used, both related and unrelated to smoking.
CTTS: Yeah. Do you do anything with your hands? Do you knit or anything like that?
PT: Oh God no. I'm the most uncoordinated person in the world. My grandmother tried to teach me for years. She said, “You're useless [laughter].” I could never do it.- Female, MA
CTTS: Yeah. See just that one puff wakes them all up again. It gets all those receptors to wake up again, and then they say, “Hey. Where have you been [laughter]?” And then you need more.
PT: We've missed you [laughter].- Female, MA
3.3 Frequency of coded behaviors
The study team compared frequency of codes between transcripts by participants' baseline anxiety and depression scores (see Supplement 1 for mean number of passages coded by baseline symptom level). Participants with moderate-to-severe anxiety and depression scores at baseline had higher frequencies of question asking, change talk, and stated importance of the live call. CTTS built off prior connections, referenced shared experience, and used empathy more frequently with participants with moderate-to-severe anxiety and depression scores, and CTTS used validation more frequently with participants with high anxiety.
4. Discussion and conclusion
To our knowledge, this study is the first to characterize both participants' and counselors' engagement behaviors by psychiatric symptomology during telephone counseling for smoking cessation in a post-hospitalization context. The goal of the current study was to generate hypotheses with the ultimate aim of optimizing engagement behaviors to render delivery of MI and other counseling techniques more efficacious. Participants often engaged by referencing past quit attempts, asking questions, using elaboration, using change talk, and expressing the importance of “live calls.” Counselors engaged by building off prior connection, expressing empathy, normalizing, reframing and summarizing, validating accomplishments, and describing shared experience. Both counselors and participants sometimes engaged with one another through general discussion of topics outside of smoking cessation and through humor. By examining these engagement behaviors in the context of participants' anxiety and depression at study entry, this study identified patterns of engagement that may inform future research and clinical efforts to maximize the efficacy of MI-based counseling content for smoking cessation.
Participant engagement behaviors offer insight into participants' informational and relational needs in the context of telephone counseling for smoking cessation, and corresponding opportunities for counselors to meet those needs. For example, participants' referencing past quit attempts may reflect a need to justify continued efforts to quit despite unsuccessful previous efforts. These references offer opportunity for counselors to reframe past quit attempts as learning opportunities, rather than failures, and to encourage long-term commitment to quitting smoking.
Counselors' engagement behaviors were largely consistent with MI. Validation and normalization are consistent with an MI focus on affirmation, reframing and summarizing with an MI focus on reflection, and building off prior connection and expressing empathy support the MI goal of collaboration. The specific examples of these behaviors provided above demonstrate tangible ways in which MI skills and strategies can be tailored to telephone counseling for tobacco cessation in everyday practice. Further, behaviors such as disclosing shared experience, whether related to smoking cessation or not, may offer opportunity for participants and counselors to connect with each other, build rapport, and strengthen therapeutic relationships.
The engagement behaviors of general discussion and humor, enacted by both participants and counselors, merit further research and exploration. These behaviors can encourage increased rapport building and reflect a strong therapeutic relationship (
Dziegielewski, 2003). However, these behaviors may also be used to cope with feelings of stress, anxiety, or embarrassment; counselors' responsiveness to these cues may be necessary for effective communication (
- Dziegielewski S.F.
International Journal of Mental Health. 2003; 32: 74-90https://doi.org/10.1080/00207411.2003.11449592
Adamle and Turkoski, 2006). For example, participants may discuss topics unrelated to cessation to avoid difficult smoking-related conversations, or because they lack clarity around the counselor's role. Humor may similarly be used defensively or as a tool to avoid difficult conversations.
- Adamle K.
- Turkoski B.
Responding to patient-initiated humor: Guidelines for practice.
Home Healthcare Nurse. 2006; 24: 638-644https://doi.org/10.1097/00004045-200611000-00007
Engagement behaviors seemed to vary among participants by their psychiatric symptoms. Participants with a greater burden of anxiety and depression symptoms during hospitalization demonstrated the highest rates of engagement behaviors during the study and their counselors concurrently made more attempts at rapport building. Future studies may explore whether GAD-7 and PHQ-8 scores may be used to identify individuals likely to benefit from targeted cessation interventions of increased frequency or intensity. Information on participants' anxiety and depressive symptoms may also be used to prime counselors to use rapport-building techniques with increased frequency.
This study analyzed randomly selected counseling calls among the random selection of calls recorded for fidelity monitoring of the parent study, which was based out of three geographic regions surrounding MGH, VUMC, and UPMC. We did not select a representative sample and cannot infer that our results would be generalizable to the broader population of smokers. However, insights that our qualitative analysis produced may be transferable to other counselor-participant interactions for the purpose of tobacco cessation and in other regions of the United States.
The sample of participants that this study analyzed may differ from the general population of smokers in ways that limit the transferability of these results. For example, this sample comprised predominantly light smokers, and results may have differed among heavier smokers. Also, as previously noted, this sample demonstrated high rates of anxiety and depression. High anxiety and depression may reflect stress associated with hospitalization when the study obtained survey measures, or reflect higher psychological distress noted among smokers (
Hebert et al., 2011;
- Hebert K.K.
- Cummins S.E.
- Hernández S.
- Tedeschi G.J.
- Zhu S.H.
Current major depression among smokers using a state quitline.
American Journal of Preventive Medicine. 2011; 40: 47-53https://doi.org/10.1016/j.amepre.2010.09.030
Jamal et al., 2012). Symptoms were likely dynamic over the course of the study in response to additional stressors. Participants with higher levels of anxiety and depression may have been more likely to request a call from a counselor or to provide survey responses that triggered a counseling call (e.g., difficulty with medication). We cannot draw conclusions regarding definitive diagnoses of depression or anxiety of study participants and can only generate hypotheses for further study based on observations noted with baseline measures of these symptoms. This study was not intended to quantitatively measure associations of engagement behaviors with reported psychiatric symptoms. This qualitative inquiry produced themes and patterns of engagement behaviors. Future quantitative studies should statistically test the hypothesis that engagement behaviors in phone counseling for smoking cessation differ based on smokers' psychiatric symptoms.
- Jamal M.
- Willem Van der Does A.J.
- Cuijpers P.
- Penninx B.W.
Association of smoking and nicotine dependence with severity and course of symptoms in patients with depressive or anxiety disorder.
Drug and Alcohol Dependence. 2012; 126: 138-146https://doi.org/10.1016/j.drugalcdep.2012.05.001
Finally, we analyzed counseling calls in this study following their completion, precluding the use of probes or targeted interview questions. The increased frequencies of counselors' and participants' behaviors observed may not be reflective of increased efficacy. Future research is needed to test the associations between participants' and counselors' behaviors and treatment efficacy using larger samples capable of testing predictive power.
4.2 Practice implications
Results of this study suggest several potential implications for telephone counseling for smoking cessation that should be investigated in future research. First, these results are consistent with other literature documenting the benefits of tailoring in response to individuals' needs. For individuals with low depression and anxiety symptomatology, less intensive engagement may suffice to prevent relapse, whereas more intensive intervention and engagement may be needed for those with moderate to severe mood symptoms. Testing this hypothesis could help to allocate counselors' limited time and resources and better match patients' needs. Further, counselors may use information on specific engagement behaviors to assess smokers' level of engagement, and perhaps adapt their own behaviors accordingly.
This study classified participant-led, counselor-led, and shared engagement behaviors during tobacco cessation telephone counseling calls. Increased rapport building and engagement may be particularly important for individuals with depression or anxiety symptoms who smoke tobacco.
The following is the supplementary data related to this article.
- Supplement 1
Comparison of mean number of passages1 coded per call by baseline symptom level.
This work was supported by the National Institutes of Health (NHBLI R01 HL111821-06). GK was supported by the Massachusetts General Hospital Department of Medicine Transformative Scholar Award. NS was supported by the Agency for Healthcare Research and Quality (T32 HS026122). KS was supported by the K12 Massachusetts General Hospital Career Development Program in Substance Use and Addiction Research (NIDA K12 DA043490).
CRediT authorship contribution statement
Kristina Schnitzer: Conceptualization, Methodology, Formal Analysis, Writing.
Nicole Senft: Conceptualization, Methodology, Formal Analysis, Writing.
Hilary A. Tindle: Funding Acquisition, Writing - Review & Editing, Supervision.
Jennifer H. K. Kelley: Writing - Review & Editing.
Anna E. Notier: Writing - Review & Editing.
Esa M. Davis: Funding Acquisition, Writing - Review & Editing.
Nancy A. Rigotti: Funding Acquisition, Writing - Review & Editing, Supervision.
Antoine Douaihy: Writing - Review & Editing.
Douglas E. Levy: Writing - Review & Editing.
Daniel E. Singer: Writing - Review & Editing.
Gina Kruse: Conceptualization, Methodology, Formal Analysis, Writing, Supervision.
Declaration of competing interest
GK reports a family financial interest in Dimagi, Inc. NR receives royalties from UpToDate, Inc., and consults about smoking cessation medications with Achieve Life Sciences. HT has served as an unpaid consultant to Achieve Life Sciences to provide scientific input into the design of a Phase 3 trial and has served as PI of NIH-supported studies for smoking cessation in which the medication was provided by the manufacturer. DS has been a paid consultant for Pfizer, Inc., on a content area separate from smoking cessation. KS, NS, DL, JK, AN, ED declare no conflicts of interest. Contents of this manuscript are the responsibility of the authors and do not necessarily represent official views of the AHRQ.
The authors would like to thank the CTTS at MGH, UPMC, and VUMC.
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Published online: October 23, 2021
Accepted: October 13, 2021
Received in revised form: September 8, 2021
Received: March 12, 2021
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