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Smoking Cessation Training in Rehabilitation Centres for Alcoholics. Comparing a Motivational (MT) and a Cognitive-Behavioural Treatment (CBT). Karin Metz, Christoph Kröger, Anneke Bühler, Carolin Donath, Stephanie Flöter & Daniela Piontek IFT Institute of Therapy Research, Munich

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Smoking Cessation Training in Rehabilitation Centres for Alcoholics

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    1. Smoking Cessation Training in Rehabilitation Centres for Alcoholics Comparing a Motivational (MT) and a Cognitive-Behavioural Treatment (CBT) Karin Metz, Christoph Kröger, Anneke Bühler, Carolin Donath, Stephanie Flöter & Daniela Piontek IFT Institute of Therapy Research, Munich EASAR 14.05.2005

    2. WIRK-Project • Funding: Federal Ministry of Education and Research (BMBF) • Duration: Nov. 2001 – Oct. 2004 • Realisation: IFT Institute of Therapy Research Munich; PI: Christoph Kröger

    3. Target Group • Alcohol addicted patients in residential treatment • in rehabilitation centres • after detoxification • duration of stay: 8 weeks to 4 months

    4. It is not a question anymore if smoking cessation during alcohol dependence treatment should be offered. It is more a question of how its effectiveness could be improved. Background • High prevalence rate of smokers in alcohol dependence treatment (80-95%) • High risk of smoking related diseases (Hurt et al., 1996) • Positive effects on alcohol abstinence (Bobo, 1989; Burling et al., 2001) • Optimal time period (window of opportunity) • Insurance companies demand smoking cessation

    5. Aims of the Study • Implementation or improvement of smoking cessation interventions in rehabilitation centres for patients with an alcohol addiction • Reaching a population with a high risk for health problems who are resistent to change their smoking behaviour • Evaluation of smoking cessation interventions (effectiveness) • Matching patients to interventions (Allocation)

    6. Setting of Smoking Cessation Interventions • 1-2 staff members (medical doctors, alcohol therapists, psychologists) were trained to deliver both interventions • Voluntary participation • One information session • Six group sessions once or twice a week (60-90 minutes) • 6 to 8 group members

    7. Topics of the Sessions - CBT • self observation of smoking behaviour (analysis of behaviour and situations; learning self control strategies) • changing smoking behaviour (reduction plan; preparation of the stop day; stop day) • stabilisation of non smoking (relapse prevention)

    8. Topics of the Sessions - MT • Emotional involvment in the topic: Environmental reactions about smoking and quitting • Consciousness rising: Quiz about objective facts of smoking and smoking cessation; Feedback of personal smoking behaviour with results of FTND • Increase ambivalence: Collection of common reasons for and against quitting smoking; Individualized decisional balance • Support to change: Personal obstacles of not quitting; Realise the power of thoughts; Cognitive restructuring of negative thoughts about smoking cessation; Brain storming; Creative solutions • Preparing to change:Mountain climber as metaphor of a smoker who is on his way of quitting

    9. Design Rehabilitation centres Nov. 02 - April 03 May 03 - Oct. 03 CBT MT 50% Rehabilitation centres MT 50% Rehabilitation centres CBT

    10. Hypothesis H1: Cognitive-behavioural treatment (CBT) and motivational treatment (MT) have the same overall success rates

    11. Data Collection • Questionaire pre treatment (T0) • Questionaire post treatment (T1) • Follow-up after 3 months (T2) • Follow-up after 6 months (T3) • Follow-up after 12 months (T4)  Outcome variable: smoking abstinence; 7 day prevalence: not smoking during the last 7 days; self reported data

    12. High interest of rehabilitation hospitals and patients in the interventions Sample • 19 rehabilitation centres • 88 smoking cessation courses (CBT: n=47;MT: n=41) • 663 alcoholic smokers (CBT: n=363; MT: n=300) • N= 29 trained staff members

    13. Dropout Analysis T0 pre-treament N=663 (100%) Dropout N= 98 (15%) T1 post-treatment N = 565 (85%) Dropout N= 269 (40,6%) T2 3 months Follow-Up N = 394 (59,4%) Dropout N= 330 (50%) T3 6 months Follow-Up N = 333 (50%) Dropout N= 339 (51%) T4 12 months Follow-Up N=324 (49%)

    14. Pretest Equivalence

    15. Unexpected high motivation of patients Stages of Change

    16. Results

    17. Effectiveness H1: CBT = MT

    18. After 12 months the abstinence rate is about 10% for the whole sample Abstinence Rates with (ITT-Analysis) and without Dropouts

    19. No difference in effectiveness of CBT and MT Abstinence Rate CBT versus MT (ITT-Analysis)

    20. Further Analyses

    21. High variance (0-22%) between hospitals Hospital- specific Abstinence Rates (T1)

    22. The specific tobacco policy of hospitals could influence the participation rate of smoking cessation interventions Interviews with staff members Smoking cessation (sc) is not effective when, • there is no adequate importance of sc in the hospital • therapist as lone fighter • hospital follows only health political pressure • there is no adequate support from staff • colleagues are smoking • lack of motivation of colleagues regarding sc • the therapist himself is unconvinced of the efficacy of sc • he is sceptical about the therapy success • he himself is a current smoker

    23. Discussion • Very high interest of hospitals and patients • The MT is as effective as the CBT. Maybe the interventions are more equal than they look like. • The MT may be favoured as a larger target group can be reached. More alcohol addicted smokers may become engaged in reflecting their smoking behaviour. • Skills training ist part of alcohol treatment where self control, stress management, relapse prevention techniques are tought. A transfer of these techniques may help smokers to become tobacco abstinent. • Improving the outcome by improving the hospital tobacco policy

    24. Recommendations (West et al., 2000) In order to send out a consistent message to smoking patients a clear tobacco policy should be self-evident: • Implementation of efficient systems for recording the smoking status • Hospitals should be smoke-free and all patients should be advised of this at the earliest opportunity • Current smokers attending hospital should receive opportunistic advice from a clinician (MI) • Offering specialist support and NRT on prescription • Clinicans and other staff who are involved in discussing smoking with patients should receive adequate training for effective interventions