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doi:10.1378/chest.06-1975
(Chest. 2007; 131:1157-1165)
© 2007 American College of Chest Physicians
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Effectiveness of an Elderly Smoking Cessation Counseling Training Program for Social Workers*

A Longitudinal Study

Gabriel M. Leung, MD, MPH; Sophia S. C. Chan, PhD, RN; Janice M. Johnston, PhD; Steve K. K. Chan, MMedSc; Pauline P. S. Woo, PhD; Iris Chi, DSW and Tai-Hing Lam, MD, MSc

* From the Department of Community Medicine and School of Public Health (Drs. Leung, Johnston, Woo, and Lam, and Mr. Chan), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Nursing Studies (Dr. Chan), Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; and School of Social Work (Dr. Chi), University of Southern California, Los Angeles, CA.

Correspondence to: Janice M. Johnston, PhD, Department of Community Medicine and School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong, 21 Sassoon Rd, Hong Kong, China; e-mail: jjohnsto{at}hkucc.hku.hk

Abstract

Background: To achieve greater coverage of the elderly smoking population, the provider/client interface could be broadened to include other professional groups who work with the elderly. We evaluated the effectiveness of a 9-h smoking cessation counseling training program for social workers.

Methods: We recruited 177 social workers and used a preintervention/postintervention longitudinal design, analyzed by multilevel, multivariable modeling to adjust for between-subjects covariables and within-subjects correlation in repeated measurements at baseline, 3 months, 6 months, and 12 months after training.

Results: Overall, knowledge improved from a mean score of 6.70 ± 1.03 (± SD) at baseline to 7.35 ± 0.75 at 12 months (range, 0 to 8 correct responses), attitude from 2.84 ± 0.41 to 3.10 ± 0.48, and self-perceived competence from 2.49 ± 0.38 to 2.85 ± 0.36 (range, 1 to 4, where 4 is best). On multilevel modeling, three of the four "A"s (ask, advice, assist, arrange as per the Agency for Healthcare Research and Quality framework) registered significant gains from baseline to 12 months overall, whereas "advice" did not show any appreciable change.

Conclusion: These findings demonstrate that our smoking cessation training program achieved sustained effectiveness in the first year after training in enhancing knowledge, positively shifting attitudes, boosting self-perceived competence, and increasing the self-reported frequency of practicing three of the four As in their routine interaction with elderly clients.

Key Words: evaluation • smoking cessation • social workers • training

Elderly persons who smoke tend to be long-term, heavy, and highly addicted smokers who are at the highest risk for smoking-attributable disease and mortality.12 Quitting smoking even at an older age can yield substantial benefits.34 However, individuals in this vulnerable group are less likely to receive smoking cessation interventions than younger people.5

Therefore, the US Agency for Healthcare Research and Quality (AHRQ) has actively promoted smoking cessation in the elderly.67 This call has been reasonably well attended to by physician groups.8 A 2004 Cochrane review9 concluded there was satisfactory evidence showing that nurse-led smoking cessation interventions can be effective. Nevertheless, the absolute proportion of elderly smokers that doctors and nurses can help is often limited due to resource constraints. This is particularly true for elderly smokers who do not present to the health system where health-care teams can intervene. Thus, to achieve greater coverage, the provider/client interface must be broadened to include other professionals who work with the elderly.

Aiming to shift entire groups of elderly smokers toward cessation,10 we propose that social workers’ participation may be helpful. Social workers are trained to identify and counsel disadvantaged and marginalized groups in the community, who are particularly at risk for smoking and are either reluctant or have problems accessing cessation services.11 A local survey of 1,499 social workers serving the elderly revealed that 19% of their clients were smokers,12 compared to a population smoking prevalence of 12.9% in the > 60-year age group.13 This confirms that social workers come into regular contact with a disproportionately large segment of elderly smokers, many of whom could benefit from cessation counseling.

We therefore organized a training program for social workers to help them understand the rationale for including tobacco dependency counseling in their portfolio and to transfer such skills. In this article, we evaluated the effectiveness of this demonstration smoking cessation counseling training program by a prospective, preintervention/postintervention design.

Materials and Methods

An outline of the training program consisting of three biweekly 3-h sessions is given in the Appendix. One hundred seventy-seven (from 124 social service units) of 1,499 social workers (from 597 social service units) who responded to a previous needs assessment exercise12 volunteered to participate in the program. They were identified from a mailed recruitment drive distributed through all 673 social service agencies providing services for clients aged ≥ 60 years. We surveyed participating social workers before and immediately after training, and at 3 months, 6 months, and 12 months by postal questionnaire. Nonrespondents were reminded by telephone follow-up every 2 weeks, to a maximum of three times.

The questionnaire was adapted from a locally validated 102-item instrument.12 The questionnaire assessed general knowledge of the health impact of smoking (4-point Likert scale, where 1 = strongly disagree to 4 = strongly agree)1415; measured knowledge about the relationship between smoking and specific diseases (1 = yes, 2 = no, 3 = do not know)14; examined attitudes toward smoking, tobacco advertising, and smoking cessation (4-point Likert scale, where 1 = strongly disagree to 4 = strongly agree)1415; enquired about smoking cessation intervention practice based on the AHRQ7 smoking cessation model (4-point Likert scale, where 1 = never to 4 = frequently); asked about self-perceived competence to deliver smoking cessation programs (4-point Likert scale, where 1 = very incompetent to 4 = very competent)14; and identified facilitators for and barriers to smoking cessation intervention14; this last section is beyond the scope of the present investigation and therefore not reported here.

We deployed {chi}2 tests to check for potential differences in respondents’ sociodemographics at baseline, immediately after training, and at 3 months, 6 months, and 12 months. Knowledge questions were dichotomized into correct vs incorrect responses, and a summary score totaling the number of correct responses (from 0 to 8) was generated. Overall mean scores, derived from the Likert responses, were computed for attitudinal items and questions on self-perceived competence in smoking cessation counseling. Actual practice responses were grouped under the four "A"s (ask, assist, advice, arrange) strategic framework,7 and mean scores were calculated for each strategy overall and their respective component items.

We then used multilevel modeling techniques1617 to analyze serial changes in the various repeated measures. Simple two-level models were specified with repeated measurements nested within individual responses. Outcomes variables included knowledge, attitude, and self-perceived competence scores and those for each of the four As smoking cessation strategies. A separate model was constructed to quantify the overall within-subjects effect of longitudinal change for each of the outcomes. All models were adjusted for between-subject covariables, including age, sex, professional registration, postgraduate qualification, staff grade, and service setting.

In addition, outcome scores at each follow-up were compared to those at the next follow-up to examine interval changes. Lastly, we compared measures at baseline with those at 12 months after training to look for overall sustained effects.

Study participants were recruited through a mailed invitation that explained the purpose of the training program, the associated research study design, and outcomes evaluation procedures. There was no incentive, financial or otherwise, offered for participation. Such details were repeated at the beginning of the training program in person, and all subjects gave verbal informed consent. The project received ethics approval from the Ethics Committee of the Faculty of Medicine, The University of Hong Kong, which complies with the Declaration of Helsinki.

Results

One hundred seventy-seven social workers registered initially, of whom 154 workers (response rate, 87.0%) completed the immediate posttraining questionnaire, 151 workers (85.3%) responded at 3 months, 153 workers (86.4%) responded at 6 months, and 139 workers (78.5%) responded at 12 months. Table 1 summarizes the respondent profiles longitudinally.


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  		Table 1.. Respondent Characteristics

 
There was an initial large improvement in social workers’ knowledge (Fig 1 , top left, a), attitude, and self-perceived competence (Fig 1, top right, b) scores immediately after training that was sustained throughout the follow-up period, albeit with slight regression to baseline. Overall, knowledge improved from a mean score of 6.70 ± 1.03 at baseline (± SD) to 7.35 ± 0.75 at 12 months (range, 0 to 8), attitude from 2.84 ± 0.41 to 3.10 ± 0.48, and self-perceived competence from 2.49 ± 0.38 to 2.85 ± 0.36 (range, 1 to 4).


Figure 1
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  		Figure 1.. Top left, a: Longitudinal changes in knowledge services. The scale ranges from 0 to 8, denoting the number of correct responses on eight questions. Top right, b: Longitudinal change in attitude and self-perceived competence scores. Bottom, c: Longitudinal changes in AHRQ scores.

 
Figure 1, bottom, c shows longitudinal changes in self-reported smoking cessation practice scores. Similar to Figure 1, top left, a, and top right, b, social workers reported undertaking all four As (ask, advice, assist, arrange) more frequently overall, although the improvement for "advice" was least marked, if at all. However, advice was also the most frequently performed task throughout the study period compared to the other three strategies. While "assist" and "arrange" scores increased monotonically, those for "ask" and "advice" showed varying degrees of decline between 6 months and 12 months after training. Table 2 details specific subcomponent interventions under each of the four As and their longitudinal changes.


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  		Table 2.. Mean Likert-Type Frequency Score (1 = Never, 4 = Frequently) and the Respondents Who Reported Practicing AHRQ Strategies at Least Occasionally*

 
On multilevel modeling that adjusted for between-subjects covariables and within-subjects correlation in repeated measurements, we see significant (p < 0.001), positive (reflected by the F values) longitudinal changes in the social workers’ knowledge, attitude, and self-perceived competence as well as the frequency at which the four As were performed (Table 3 ). Further attributing these changes to discrete intervals, the models confirmed that most of the increase in knowledge, attitude, and self-perceived competence scores was generated between baseline and immediately after training. Small regression in scores was statistically significant for knowledge and attitude outcomes but not for self-perceived competence. There was no further significant decline after the 3-month follow-up. In the adjusted models, only three of the four As registered significant gains from baseline to 12 months overall, whereas advice did not show any appreciable change (Table 3). Most of this lack of progress was likely driven by a decrease in outcome scores for "explain to clients how smoking may have contributed to their illness" and a flat serial trend for "advice to stop smoking" (Table 2).


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  		Table 3.. Multilevel Modeling on the Effect of the Training Program on Knowledge, Attitude, Self-Perceived Competence, and Practice of AHRQ Strategies*

 
In terms of individual characteristics that predicted change in outcomes, Table 4 shows that seniority/experience (as proxied by staff grade) was consistently associated with more frequent practice of the four As. The work setting also showed some association but with borderline significance at the 0.05 level. Older social workers in the program also had greater self-perceived competence in smoking cessation counseling.


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  		Table 4.. Multilevel Modeling on the Effect of Individual Level Covariables on Knowledge, Attitude, Self-Perceived Competence, and Practice of AHRQ Strategies*

 
Discussion

Given evidence from the Lung Health Study18 showing that smoking cessation "can have a substantial effect on subsequent mortality, even when successful in a minority of participants," it has become imperative to offer smoking cessation services to all current smokers, especially those who are at highest risk. The elderly belong to this group. Paradoxically, they are often overlooked as prime target clients in such programs. Part of the reason lies in the fact that a substantial number do not present to the health-care system or are missed from preventive health counseling during clinical encounters. We therefore extended our reach to this susceptible group by broadening the provider/client interface to train social workers as additional first-line smoking cessation counselors. This study adds to the scanty literature on smoking cessation training for nontraditional health-care providers.

Previous studies on smoking cessation training have reported positive results in medical students,1519 dentists,20 and residents,21222324 but negative findings in two other studies2526 of family practice trainees. In addition, similar to our intent on broadening smoking cessation counseling beyond doctors and nurses, Hudmon and coworkers2728 published encouraging results, in terms of perceived abilities and confidence for providing tobacco cessation counseling, from administering the 8-h "Rx for change" program to pharmacists. Another US model, the Arizona state-wide community-based model for certification of tobacco cessation skills training, also reported initial success in improving skills and frequency of counseling.29

The present findings add to this body of literature by clearly demonstrating that our 9-h training program, specifically tailored to local social workers based on a prior population-based learning needs assessment, achieved sustained effectiveness in the first year after training in enhancing knowledge, positively shifting attitudes, boosting self-perceived competence, and increasing the frequency of self-reported practice of three of the four As as per AHRQ guidelines. Of note, the knowledge, attitude, perception, and perhaps most importantly self-reported practice indexes mostly moved in parallel and showed similar directional changes: a phenomenon that is not always observed in other studies. In fact, an often-repeated refrain cautions against the commonly observed lack of synchronicity or decoupling of these outcome measures. Since we tracked longitudinal changes at multiple time points, our data were more detailed than in many other previous studies and therefore might have accounted for the clearer synchronous pattern through time as opposed to cross-sectional measurements at the beginning and end only. While such observations likely represented the true parallel improvements in the various outcomes, we cannot rule out misreporting of the practice outcomes according to their self-perceptions and knowledge base, thus artifactually giving rise to the apparent synchrony. If however the findings are real, we could perhaps understand the observed continuity from knowledge, attitude to behavior in that the present investigation assessed a relatively straightforward extension of the social workers’ portfolio where the usual assumption of the rational-actor perspective in many models of human behavior is more valid than say for other behaviors that concern personal health-promotive or health-protective actions.

Concerning the invariance of the advice frequency scores, we speculate this was because these social workers were already highly skilled at offering advice; in fact, this had been a key component of their daily routine. Compared to the other three As, where there was more room for improvement, it was difficult to improve on this core skill inherent in social work as reflected by its already much higher frequency of self-reported practice. Nevertheless, given a ceiling of 4 on the Likert scale, there was still considerable scope for enhanced practice of this strategy overall (which peaked at 2.39), notwithstanding the usual response bias toward the middle categories on Likert scales. Of note, the two items under advice that actually showed a decline, while they may be spurious, should be re-emphasized in the program curriculum and deserve closer attention in future studies. In addition, there may be systemic or organizational factors affecting the practice of smoking cessation counseling that are difficult to overcome even with intensive training.26 For example, Cornuz et al22 showed that training residents to deal with tobacco dependency, while generally successful in increasing the quality of counseling, smokers’ motivation to quit and 1-year abstinence rates, had no significant effect on improving participants’ frequency of delivering advice to quit.

Several potential caveats bear mention. First, our outcomes were proxy process measures. We did not collect information on clinically relevant outcomes of quit rates among elderly smokers counseled by social workers or ultimately morbidity averted or lives saved as a result of smoking cessation. However, this would have required much longer follow-up and a randomized controlled design, with the associated large resource commitments that were beyond the scope of the present demonstration project. In addition, social workers are often the initial contact point for smokers, especially those who would otherwise not have been counseled, but many are subsequently referred to the health-care system for more intensive medical and nursing interventions and pharmacologic treatment. Therefore, it becomes very difficult to attribute the overall quit successes between social and health services, except for in the setting of a large community-based cluster randomized trial with a defined sample including those smokers who normally would not present to the health system. Second, we adopted the old four As framework, having omitted "assess" from the current AHRQ five-pronged strategies, because the training protocol was developed prior to the release of the 2000 guidelines. This may limit the comparability of our results to the latest literature. Third, the usual limitations of nonrandomized observational evaluation such as unobserved and residual confounding apply. Fourth, our outcomes were based on self-reports rather than direct measurements, thus exposing the results to potential responder bias. For instance, Adams and colleagues30 showed in a systematic review that self-reported adherence to clinical guidelines tended to overestimate actual practice when benchmarked against objective measurements. In our setting where the respondents had participated in a training program, the moral hazard of inflated self-reports may be even more substantial. Nevertheless, it is hard to imagine respondents deliberately skewing the results consistently over five separate surveys spanning 1 year.

Future efforts should focus on confirming the effectiveness of our training program for other groups who come into regular contact with smokers and in other sociocultural settings, particularly in China and East Asia. In addition, a large randomized controlled trial to demonstrate definitive clinical benefits and cost-effectiveness of this approach to training in smoking cessation counseling is warranted.

Appendix

Curriculum Outline of the Elderly Smoking Cessation Program

Formula

Acknowledgements

We are grateful to the Social Welfare Department and the Hong Kong Council of Social Services for facilitating recruitment of social workers. Dr. Leung thanks the Takemi Program at the Harvard School of Public Health for hosting his sabbatical leave during which the writing of this work was completed.

Note: A variety of teaching methods such as didactic lectures by academics and service sector experts, video consultations, and testimonials of ex-smokers and counselors were adopted. The curricular content was modified and abbreviated from an established smoking cessation counselor certification course for nurses in Hong Kong. To help design the training curriculum, an evidence-based learning needs assessment was first performed among a population-based sample of social workers who worked with the elderly.12 These responses highlighted areas of knowledge and skills deficiency,12 which were then particularly emphasized in the training course. Specifically, social workers reported weaker knowledge of the impact of smoking on health and held a less positive attitude towards smoking cessation counseling compared with nurses. However, since social workers generally perceived themselves as more competent in counseling and outreach with clients, we did not emphasize generic skills in client/provider communication as much but spent more time on reinforcing the adverse biological and health effects of tobacco dependency, thus justifying their intervention to improve quality of life for their clients.12

Footnotes

Abbreviation: AHRQ = Agency for Healthcare Research and Quality

This work received funding from the Community Partnership Scheme, Elderly Commission, Health Welfare and Food Bureau, Government of the Hong Kong Special Administrative Region.

The authors have no conflicts of interest to disclose.

The sponsor has no role in the design, methods, subject recruitment, data collections, analysis, preparation, or submission of the article.

This work formed part of the dissertation requirements for Mr. Chan’s master’s studies at the University of Hong Kong.

Received for publication August 10, 2006. Accepted for publication November 22, 2006.

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