Randomised controlled trial of home based motivational interviewing by midwives to help pregnant smokers quit or cut down

Sir, This study and its discussion, published in the middle of
August, will be a disappointment to many medical educators in medical
schools, who aim to teach evidence based practice.

For those of us in medical education, trying to establish basic
health promotion skills in core undergraduate curricula, especially
related to the major public health issues, this study raises some
concerns.

The rapid responses to date highlight some of the issues that need to
be addressed but I would also draw your attention to some additional
factors that should be considered.

Brief Intervention and motivational interviewing have gained currency
in part because their efficacy is related to the clinician having the
skills to determine the level of motivation before proceeding to offer
intervention. There is now wide spread use of these skills in the primary
care sector smoking cessation services.

Smokers who want to quit seek help and are motivated to change.
Pregnant smokers may neither be motivated nor empowered to make changes.
Their factual knowledge that smoking is potential harmful may not be in
doubt but their locus of control and multiple social external factors may
be powerful barriers to change. This study appears to have used techniques
applicable to the motivated smoker but as Tappin et al point out in their
discussion, the intervention group may have included “heavier, more
dependent smokers”. However well trained the midwives were we surely
need to question whether the intervention was appropriate for the patient
in this context.

Teaching about smoking cessation intervention involves both teachers
and students exploring the literature and determining what can be
attributable to brief intervention in practice.
Many successful quitters will have experienced relapse but will also have
received support through that phase, they are likely to be in environments
where smoking restrictions are enforced and where non smoking is a social
norm. This may not be the case for the participants in the study.

Pregnant smokers themselves face many challenges and a qualitative
study to gain some insight into their more immediate concerns may have
yielded richer and more relevant data to help improve care and support.
Are there any plans to follow up the women? if so, they may yet provide a
useful retrospective contextual view on the intervention experience.

Competing interests:
None declared

At the outset, we understood that a negative result for this trial
(1) would be followed by many questions. Not least was whether the
quality of home-based Motivational Interviewing (MI) provided by the
midwives was high enough for it indeed to be judged as MI. We are in the
process of writing a paper describing the method of teaching and the
results in terms of quality of motivational interviewing.

The midwives were taught MI by Jeff Allison. He also supervised their
practice throughout the study, and was recommended by Dr Stephen Rollnick
(2) because of his acknowledged expertise and international experience.
Jeff Allison is a training consultant who has specialised in teaching MI
and other health behaviour change techniques for the last ten years. He is
a member of the MINT (Motivational Interviewing Network of Trainers)
organisation and also trains other MI trainers. Most health professionals
he teaches receive limited training because of time and budgetary
constraints. For this trial, Jeff was asked to train the midwives to a
standard of sustained competence above the minimum threshold as recognised
by the various validated assessment instruments. During the first two
months the midwives received 8 days of intensive training. They then
started to provide the home-based intervention and all sessions were audio
-recorded. Every month, each midwife chose at least one ‘problematic’
interview which was then transcribed by the administrator. This was the
subject of mentoring one day per month by Jeff Allison when interviews
were discussed line-by-line to improve practice and maintain competence at
the required level. Evelyn Mohammed, the lead research midwife, attended
an MI Training for Trainers workshop.

A random 10% sample (n=63) of all 625 home-based intervention
interviews were transcribed and sent, with the recordings, to CASAA
(Center on Alcoholism, Substance Abuse and Addictions) at the University
of New Mexico, established by Professor Miller (2), to formally examine
the quality of the Motivational Interviewing provided by the midwives. No
one in the UK had any influence, whatsoever, on this assessment. CASAA
provided a rating service using the MISC (Motivational Interviewing Skills
Code) (3). Table 2 of the web version of the paper (www.bmj.com) describes
the quality of MI in the home-based intervention interviews. The midwives
could be described as “experts” at providing motivational interviewing in
this setting. Dr Theresa Moyers at CASAA listened to many of the 63
randomly selected interviews and supervised the rating team. She
commented, ‘I want to tell you again how much my coders enjoy coding your
sessions. They hear a lot of not-so-MI MI and the quality of counselling
delivered by the midwives really stands out.’ The motivational
interviewing provided by these midwives was of a good standard.

We should not conclude from this trial that MI is off little help in
this situation. It may not, however, be enough on its own to promote
profound change in Glasgow. Interventions that do work in such deprived
communities (4) will help address health inequalities and are likely to
work elsewhere. In Glasgow smokers are identified at maternity booking by
every woman routinely performing a carbon monoxide breath test. We should
treat Motivational Interviewing as it was designed - an effective way to
begin to talk to these pregnant women about smoking, a health behaviour
that is damaging themselves and their offspring, and how it fits into
their lives. The style of MI – quiet, respectful, non-confrontational,
collaborative – is far more appreciated than the traditional concerned but
hectoring manner of many health professionals. Once smokers are engaged
and talking, they can tell us if they want to quit and we can provide
appropriate behaviour therapy to aid a quit attempt. Once trials have
shown that Nicotine Replacement Therapy is safe and effective in pregnancy
this may be employed to support behaviour therapy during a quit attempt.

1. Tappin DM, Lumsden MA, Gilmour WH, Crawford F, McIntyre D, Stone
DH, Webber R, MacIndoe S, Mohammed E. BMJ 2005;331:373-7.

2. Miller WR, Rollnick S. Motivational Interviewing: Preparing People
for Change. 2nd edition. New York: Guilford Press. May 2002.

3. Moyers T, Martin T, Catley D, Harris KJ, Ahluwalia JS. Assessing
the Integrity of Motivational Interviewing Interventions: Reliability of
the Motivational Interviewing Skills Code. Behavioural and Cognitive
Psychotherapy 2003; 31:177-84.

4. Carstairs V, Morris R. Deprivation: Explaining differences in
mortality between Scotland and England and Wales. BMJ 1989; 299: 886-9.

Competing interests:
Jeff Allison is a training consultant in Motivational Interviewing and other health behaviour change therapies

I found the report of the study by Tappin and colleagues to be very
interesting and it is potentially important in that Motivational
Interviewing is still in a growth phase and we surely need to understand
its limits. Talk based therapies are not usually cheap (just under one
hour of extra professional time per patient in this study) and we need to
invest in them where they work and are cost effective, and invest
elsewhere if they are not.

Like Morgan, I was very impressed by the external quality control in
this study and somewhat frustrated at not having more details about the
consultant who provided the training and about the nature of the training.
I join Morgan in asking if these could be provided in an author response?

However, my main point is with an aspect of the design i.e. that of
using Motivational Interviewing AS WELL AS normal care in this study. If
normal care were based on the model of "present lots of facts and expect
rational processing to lead to behaviour change" then the potential
benefit of a Motivational Interviewing approach might easily be lost in
the context of the "tell and sell" approach.

So it seems a bit early to conclude that a Motivational Interviewing
approach cannot affect the quit rate for pregnant smokers, although I am
now alert to the possiblility that this might be so.

Competing interests:
Director of EFFECTIVE PROFESSIONAL INTERACTIONS - skills based communication training for doctors, nurses and allied professionals