A Motivational Intervention to Reduce Cigarette

Transcription

1 A Motivational Intervention to Reduce Cigarette Smoking Among College Students: Overview and Exploratory Investigation Keith C. Herman and Beth Fahnlander College counselors can play an important role in implementing brief strategies that will motivate students to stop smoking cigarettes.the authors provide an overview of motivational interviewing, a specific protocol that can be applied to college student smoking.the authors also present preliminary evidence of the success of this approach in promoting abstinence from smoking and a desire to change among college smokers. E ach day, more than 5,000 people smoke their first cigarette (Centers for Disease Control and Prevention [CDC], 1998). Of these individuals, more than two thirds (more than 3,000) are teenagers who are not even old enough to legally purchase cigarettes (CDC, 1998). Even for those who are only experimenting with cigarettes, the risk of addiction is overwhelming. According to the CDC (1998)) 55% of individuals who smoke more than 100 cigarettes will continue smoking until the year of their death. Despite known health risks, smoking prevalence remains high across all age groups. At least 23% of adults in the United States smoke cigarettes (CDC, 1998). Moreover, a recent report issued by the CDC (2000) indicated that the smoking rate among high school students had risen from 27.5% in 1991 to 34.8% in Similarly, from 1993 to 1997, the smoking rate among college students increased from 22.3% to 28.5%. This increase was seen across all student subgroups regardless of gender, race/ethnicity, and year in school (Wechsler, Rigotti, Gledhill-Hoyt, & Lee, 1998). Although there have been advances in smoking cessation treatment during the past decade, treatment success rates remain discouragingly low. Even comprehensive, multimodal treatmenr approaches yield 6-month abstinence rates of 40% or less (see Ockene et al., 2000, for a review of treatment approaches). One bright spot regarding treatment innovations has been the success of timelimited interventions in helping people alter substance use patterns (see Bien, Miller, & Boroughs, 1993; Bien, Miller, & Tonigan, 1993; Miller, 1995). Brief interventions have been among the most promising treatments for reducing problematic substance use, including alcohol and smoking, among college Keith C. Herman and Beth Fohnlander, Psychology Department Reed College. Portions of this article are based on the second author s senior thesis. The authors thonk Michael lombordo and Michael Taylor for their assistonce in administering the study interventions and the Health Center staff at Reed College for their support. Correspondence concerning this article should be sent to Keith C. Herman, Psychology Deportment, Reed College, SE Woodstock Blvd.. Portland, OR I99 ( khermon@darkwing.uoregon.edu). 46 Journal of College Counseling Spring 2003 Volume 6

2 students (Borsari & Carey, 2000; Marlatt et al., 1998). In a recent shidy, for example, Borsari and Carey investigated the efficacy of a one-session intervention in reducing substance use among binge drinkers. Compared to a no-treatment control group, participants who received the one-session intervention reported a lower number of drinks consumed per week, fewer drinking occasions per month, and fewer binge drinking episodes at 6-week follow-up. Borsari and Carey concluded that the 1-hour intervention significantly reduced both the frequency of drinking and the amount of alcohol consumed. Brief interventions may also help to reduce cigarette smoking among adults and adolescents (Colby et al., 1998; Rollnick, Butler, & Stott, 1997; Rollnick & Heather, 1992). Rollnick et al. (1997) described, but did not evaluate, a promising brief motivational interview that was designed to reduce smoking among adults in a general medical practice. Similarly, Colby et al. reported some success in administering a single motivational interview to adolescents in a hospital setting. Twice as many participants in the treatment group reported abstinence at 1 -month follow-up, as compared with participants who received brief advice to quit smoking. However, the effect was small (effect size [ES] =.28), and no other comparisons were significant. The researchers concluded that motivational interviewing warrants further investigation as a treatment for reducing smoking among adolescents, a conclusion echoed in a recent meta-analysis of motivational interviewing outcome studies (Burke, Arkowitz, & Dunn, 2002). In addition to studying brief motivational interventions, finding ways to disrupt the common progression from teenage experimentation to lifelong cigarette smoking holds promise for reducing societal smoking rates (McNeill, 1991). A lengthy smoking history and a strong physiological dependence on nicotine make it more difficult for smokers to stop smoking (Ockene et al., 2000). Interventions that are implemented early in the addiction cycle, before nicotine dependence occurs, may be more effective than interventions that occur later in the cycle. The time when young adults first enter college may be an opportune time to disrupt progression toward smoking addiction for several reasons. First, for many individuals, college age is still early in the individual s smoking history. Second, beginning college represents an important developmental transition period. Thrd, college entry creates an important contextual change wherein previous stimuli that initiated and helped maintain smoking behavior (eg, high school friends, settings) are no longer present. Although smokers quickly develop new cues for their smoking behavior, at college entry these cues may initially be less persuasive and more responsive to change. Thus, entry into college may provide a unique window of opportunity to alter the smoking behaviors of light and moderate college-age cigarette smokers, thus halting possible progression to nicotine dependence. College counselors can play an important role in implementing brief motivational strategies to promote student motivation to stop smoking. We provide an overview of motivational interviewing, a specific protocol that can be applied to college student smoking, and preliminary evidence of the success of this approach in promoting abstinence from smoking and a desire to change among college smokers. Journal of College Counseling.. Spring 2003 Volume 6 47

3 Overview Motivational Interviewing Motivational interviewing (MI) is a time-limited treatment strategy that combines humanistic principles with an emphasis on personal responsibility and resolving client ambivalence about changing (Miller, 1995; Miller & Rollnick, 2002). Five guiding principles help counselors structure MI sessions: express empathy, develop discrepancy (i.e., the ability to distinguish between what the client is doing and what he or she wants to be doing), avoid arguments, roll with resistance, and support the client s self-efficacy (Miller, 1995). The structure of an MI session, which is based on a stage of change model (Prochasca, DiClemente, & Norcross, 1992), is intended to promote client self-reflection, especially regarding contradictory beliefs and actions. MI counselors evoke change talk, or self-motivated speech, by asking evocative questions (e.g., What are the disadvantages of the status quo? What are the advantages ofchange?), using importance rulers (described later in this article), querying extremes of the problem behavior, and exploring values and goals (see Miller & Rollnick, 2002). Lawendowski (1998) noted, A high priority is placed on reflecting the self-motivational statements in order for the client to hear his/her concerns and reasons for change at least twice: once from the self and at least once from the therapist (p. A39). The MI counselor makes a special effort to emphasize the client s own reasons for quitting and to remove the barriers that discourage the client from changing. A Motivational Interview Protocol for Smoking Cessation We developed a treatment manual, using MI principles and other MI protocols (e.g., Brown, Ramsey, & Sales, 1998; Miller, Zweben, DiClemente, & Rychtarik, 1992). The 50-minute intervention includes seven components: (a) rationale, (b) decisional balance, (c) nicotine dependence, (d) smoking norms, (e) financial costs of smoking, (9 carbon monoxide feedback, and (g) future plans regarding the participant s smoking behavior. First, because the manual was designed for use with students regardless of their intention to stop smoking, sessions begin with a 5-minute discussion of the rationale for the meeting ( to learn more about smoking on campus and to help [the student] think about [his or her] own smoking ). Counselors clearly state their own biases and offer advice ( As a health care professional, I think it is a good idea for you to quit smoking ) while simultaneously supporting the client s responsibility for change ( I also realize it is completely your decision to make. No one can change your smoking but you ). It also helps to add that the counselor does not intend to coerce the client to change. Such frank discussion usually puts clients at ease because they learn that the counselor will be direct and will not attempt to persuade them to make undesired decisions. These steps are also consistent with motivation enhancement philosophy and strategies (e.g., advice giving and responsibility are components of effective brief interventions; see Miller, 1995) Journal of College Counseling Spring 2003 Volume 6

4 Second, counselors and clients have a structured discussion about the advantages and disadvantages of change, beginning with positive aspects of smoking ( 10 minutes): What are some good things about smoking? After repeated prompts for additional positives ( Anything else? ), counselors elicit any negative aspects of cigarette smoking. We have found that clients easily engage in this activity and are able to provide many examples for each side. The decisional balance helps to highlight the client s ambivalence about ending the smoking habit. Counselors rely on listening skills to gather additional information from the client and to reflect any statements that the client makes about the need for changing the smoking habit (ix., change talk). In addition, counselors elicit any client concerns about quitting smoking (offering a hypothetical If you were to quit someday... ) and benefits of quitting. When this and all subsequent sections have been completed, the counselors summarize the client s statements, with special emphasis on change talk. Third, clients complete a briefmeasure ofnicotine dependence (Lea the Fagerstrom Tolerance Questionnaire: Adolescent Version [ FTQ]; Prokhorov, Pallonen, Fava, Ding, & Niaura, 1996), and they calculate their score while in session (5 minutes). The counselor provides information about the meaning of nicotine dependence and about the increasing difficulty of quitting as dependence progresses and persists. The implications are that (a) nicotine replacement strategies may be needed for clients who have high scores on the FTQ and (b) quitting sooner rather than later makes sense for clients who have low scores. Fourth, counselors provide information about national and local smoking norms (5 minutes). Research has shown that adolescents who use substances greatly overestimate the number of peers who also use substances; providing accurate norm data promotes motivation to change (Schroeder & Prentice, 1998). Some examples of norm data that may be provided to clients include the percentage of students nationally and locally who are cigarette smokers, the percentage of teenage smokers who expect to be smoking 5 years after graduation (5%) versus the percentage who are smoking 5 years after graduation (75%), and the percentage of smokers who want to quit (70%). These data are presented in an elicit response/provide feedback/elicit reaction format (e.g., asking clients to guess each response, providing the correct information, then eliciting their reaction to the correct information). Fifth, counselors help clients calculate the costs of cigarette smoking, that is, how much money they spend each year on smoking (5 minutes). After calculating yearly expenditures, reactions are elicited, and clients are asked to consider how else they might spend that money. Counselors ask for specific examples, write them down, and encourage the client to spend all of the yearly sum on the examples they have provided. Sixth, counselors provide clients feedback about their carbon monoxide (CO) levels (5 minutes). Counselors determine clients CO levels, using the smokerlyzer, a hand-held device that measures the amount of carbon monoxide in the lungs. Before giving clients their score, counselors ask clients what they know about CO and provide missing information regarding what CO is (e.g., a tasteless, colorless, odorless, and toxic gas ) and how it is harmful to the human body Journal of College Counseling 8 Spring Volume 6 49

5 (e.g., it interferes with the transport of oxygen to vital organs). Counselors provide students with their score and norm data (e.g., nonsmokers tend to have blood CO levels of 10 parts per million [ppm] or lower, light-to-moderate smokers have CO levels of ppm, and heavy smokers have CO levels of ppm). Scores may be underestimates, depending on when the client last smoked; CO levels decline sharply within a couple of hours after the last cigarette. Smokerlyzers can be purchased from medical supply companies or borrowed from local agencies, such as the American Lung Association. Alternatively, college counseling center administrators might consider purchasing spirometers (or borrowing them from campus health centers, if available). Spirometers provide a more comprehensive measure of lung function and allow the computation of lung age. These are also available for purchase from medical supply companies. After summarizing all the session components, the counselor concludes the discussion by asking structured questions about the client s future plans (15 minutes). Scaling questions, or rulers, are used to assess the client s perceived importance of change ( On a scale of 0-10, zero being not important at all, 10 being the most important thing in your life, how important is it for you to change your smoking? ) and confidence ( How confident are you that you could change your smoking? ). Regardless of clients responses, counselors next ask (a) how they chose their ratings ( Why did you rate it a and not one lower? ) and (b) what it would take to get them to move 1 or 2 points higher on each scale. Importance and confidence rulers evoke change talk and statements that support client self-efficacy (see Miller & Rollnick, 2002). Counselors then help clients develop a change plan that is based on their responses to the ruler questions. Clients set goals related to their smoking and identify steps toward the goal, their resources, and the potential barriers. Finally, counselors ask clients to again rate their confidence levels to see if the plan promoted confidence in their ability to change. At the end of the session, the counselor smmarizes the entire session and gives the client any completed worksheets (e.g., decisional balance, costs, and future plans) and a list of resources to help with smoking cessation. In the context of the controlled study described later in this article, we adrninistered the treatment in a single session; thus, we could not conduct follow-up sessions. However, in practice it would be advisable to include subsequent sessions if the client is interested and willing to do so. Other components that are not included in the manual but that may be useful for exploration in subsequent sessions include examining the impact of smoking on appearance (e.g., wrinkles, tooth color, smell) and assessing the relationship between smoking and the client s smoking network (e.g., individuals in their lives who are cigarette smokers and how friends and family respond to their smoking). Exploratory Investigation To test the usefulness of MI as a single brief intervention for college student smokers, we conducted an exploratory study in which we compared the out- 50 Journal of College Counseling = Spring 2003 = Volume 6

6 comes for students who received a one-session MI versus a no-treatment control group. Specifically, we hypothesized that participants in the treatment condition would be more likely to have quit smoking at 6-month follow-up and to be in an action-oriented stage of change. We also hypothesized that participants in the treatment condition would report smoking fewer cigarettes per week, experiencing less nicotine dependence, and making more attempts to quit compared with the control group, controlling for baseline scores on these variables. Finally, given the brevity of the intervention, we predicted that light smokers (those who smoked fewer than 10 cigarettes per day at baseline) would benefit most from the intervention. Method Eligibility criteria for participation in the study required that participants be currently enrolled at a small liberal arts college in the northwestern United States and report smoking cigarettes at least once a week for the past 4 weeks (a common definition of a regular smoker ). Desire to quit smoking was not required. A total of 42 students participated in the study (22 women and 20 men); all were Caucasian. The control group consisted of 22 students: 11 women and 1 1 men. The intervention group consisted of 20 students: 11 women and 9 men. The mean age of the control group participants was 20.8 years (SD = 1.61). The mean age of the participants in the treatment group was 20.5 years (SD = 1.47). No significant differences existed between the two groups on any of the demographic or smoking variables at baseline. After completing the informed consent form, participants were randomly assigned to treatment condition. The questionnaire used at baseline and follow-up included items that elicited information on demographic characteristics (age, gender, year in school), smoking status (number of cigarettes smoked per day and week and number of smoking days per month), smoking history (number of past attempts to quit, age at which first cigarette was smoked, age when regular smoking began), predicted quit age (i,e., If you envision yourself quitting in the future, what age do you think you will be when you quit? ), smoking dependence (as measured by the FTQ; Prohorov et al., 1996), and drug use. Participants also rated their motivation to quit and confidence that they could quit ininiediately on scales from 1 (not at all motivated/confdent) to 10 (very motivated/ confident). At 6-month follow-up, participants completed additional measures regarding their smoking status (7-point prevalence, i.e., a detailed account of cigarettes smoked on each of the previous 7 days, if any) and stage of change (modified Readiness to Change Questionnaire with the word smoking substituted for alcohol; Rollnick, Heather, Gold, & Hall, 1992). After completing an informed consent form, all participants completed the baseline questionnaire. Participants in the treatment condition then scheduled an appointment to meet with a smoking counselor within the week following the baseline assessment. Participants in the control condition received no intervention but were provided with resources when they requested them and at the Journal of College Counseling Spring Volume 6 51

7 end of the study. Researchers contacted all participants 1 month after baseline and asked them to complete a brief measure of smoking status. Six months after completing the baseline questionnaire, participants completed the full follow-up questionnaire, which included detailed questions about smoking status and stage of change. Two participants in each group failed to complete the 6-month follow-up. Interventions were given by a counseling psychologist and two master s-level clinicians. To ensure that all three counselors delivered the same intervention, the previously described treatment manual was used by all the counselors. The first author, who has extensive experience with MI, trained the other two MI counselors during three 1.5-hour training sessions. Before the first training, the counselors read literature regarding MI (Miller, 1995). As an additional step to ensure treatment integrity, the counselors documented their compliance with the protocol and noted any session irregularities in a research note. Res u 1 t s The primary outcome variable was 1-week point prevalence (smoking abstinence for the prior week) at 6-month follow-up, measured by self-report. Logistic regression analysis, controlling for baseline number of cigarettes per week, revealed a significant effect of treatment condition on smoking status, x2( 1, N = 40) = 4.80, p =.028. In the MI group, 15% of the participants reported abstinence at 6-month follow-up compared with 0% in the control group. However, there were no significant stage of change differences between the two groups, x2( 1, 40) = 3.07, p =.216, nor were there significant differences between the two groups at 6-month follow-up on self-reported number of cigarettes per week, 438) =.06, ns; smoking dependence, (38) =.749, ns; or number of quit attempts, 438) = 1.29, p =.207. Three multiple regression analyses were conducted to determine if treatment condition predicted number of cigarettes per week, (38) =.004, ns; smoking dependence (FTQ), t(38) =.563, ns; or quit attempts, 438) = 1.50, p =.14, when controlling for baseline scores on each of those variables; none of the results of these analyses were significant. We repeated the same analyses with a subgroup who smoked fewer than 10 cigarettes per day at baseline to test our hypothesis that the intervention would be most effective for light smokers. The primary outcome variable was 1- week point prevalence (smoking abstinence for the prior week) at 6-month follow-up, measured by self-report. Logistic regression analysis, controlling for baseline number of cigarettes per week, revealed a marginally significant effect of treatment condition on smoking status, x ( 1, 19) = 3.13, p =.077. In the MI group, 25% of the light smokers reported abstinence at 6-month follow-up, compared with 0% in the control group. There were significant stage of change differences between the groups, x2(1, 19) = 7.66, p =.02, such that significantly more light smokers (62%) who received the treatment were in the action stage of change at 6-month follow-up compared with participants in the control group (27%). Light smokers in the MI group also reported significantly lower smoking dependence (M= 1.4 vs. 2.5; ES = 1.19) at 52 Journal of College Counseling Spring 2003 Volume 6

8 6-month follow-up, t(19) = 2.51, p =.02, although this univariate finding did not persist when controlling for baseline FTQ score, t( 19) = 3.76, p =.lo. The groups did not differ significantly on self-reported number of cigarettes per week,t(38)= 1.18,p=.25,ES=.55,ornumberofquitattempts,t(38)= 1.59, p =.13, ES =.88, at 6-month follow-up although all mean differences (M = 16.8 vs and M= 2.6 vs. 1.0, respectively) were in the predicted direction. These mean differences represented medium to large effects. Discussion Our findings support the continued application and study of a single, brief motivational interview for reducing cigarette smoking among college students. Students who received the brief intervention were more likely to report abstinence at 6-month follow-up when compared with a no-treatment control group. Light smokers (participants who smoked fewer than 10 cigarettes per week at baseline) may have benefited the most from the intervention. Light smokers in the treatment group were more likely to be in the action stage of change 6 months after the intervention, and they reported lower smoking dependence scores at followup as compared with light smokers in the control group. The effect sizes observed in the present intervention exceeded those reported by Colby et al. (1998), likely a result of different participants (hospitalized adolescents vs. college students), settings (hospital vs. college), and comparison condtions (brief advice vs. no treatment). The effect size of the present intervention would almost certainly be smaller if a brief advice condition had been used for comparison. For example, whereas no participants in the control condition reported abstinence at follow-up, 10% of comparison participants in Colby et al. s study were abstinent at follow-up. Further research is needed to confirm our findings. Given the possible improved outcome for light smokers, future research and applications might best use a stepped-care model approach wherein light smokers receive the single intervention described in the present study and heavier smokers receive two or more sessions. A single intervention may not be strong enough to sustain behavioral change for heavier smokers, given complicating factors such as longer smoking history and more severe nicotine dependence. Marlatt et al. (1998) reported success in using a steppedcare approach with problematic drinkers in a college setting. The findings must be tempered with an appreciation of the limitations of this study. First, the study did not use a contact control condition, and thus we cannot determine the contributions of nonspecific therapeutic effects (e.g., therapist attention) that are unrelated to MI strategies. A future study is needed to contrast MI with a brief advice condition to determine the specific effects of MI. In addition, future research should include measures of hypothesized mediators of change (e.g., awareness of smoking norms) that are consistent with MI theory. Second, the study relied on self-report by.. Journal of College Counseling Spring 2003 Volume 6 53

9 the participants and was unable to confirm abstinence through biochemical testing. Biochemical confirmation would be an important addition to future studies. Third, the small sample size and unique sample pool may limit the generalizability of findings beyond the student sample in the present study. It is also important to note that not all hypotheses were supported in the present study. Although participants who received the MI treatment were more likely to report abstinence at 6-month follow-up, as a group, they did not report smoking fewer cigarettes. All group differences were in the predicted direction, however, suggesting that low power may have been a limiting factor in some analyses. Power limitations are of special concern given the numerous marginally significant findings that were, nevertheless, represented by effect sizes of moderate to large magnitude. A followup study with a larger sample would help address these concerns. Conclusion College counselors play an important role in promoting the health of students. Given the dire consequences of a life course of persistent cigarette smoking and the developmental roots of smoking behaviors in adolescence and early adulthood, college counselors are encouraged to consider, as a part of their healthpromotion role, interventions that discourage cigarette smoking. Whether integrated into their existing practice with students or developed as separate campuswide initiatives (similar to drinker check-up days), the MI strategies that we describe in this article give college counselors multiple strategies for addressing student smoking behaviors. The MI approach is gaining support, and a growing body of research is affirming its place in the canon of effective treatment approaches. Given mounting pressures toward time-limited therapy, counselors and researchers welcome any evidence that single-session interventions can promote lasting change. Current evidence suggests that single sessions that are based on MI strategies offer a viable treatment to reduce problematic substance use in college settings. References Bien, T. H., Miller, W. R., & Boroughs, J. M. (1993). Motivational interviewing with alcohol outpatients. Behaviuural and Cognitive Pychotherapy, 21, Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, Borsari, B., & Carey, K. B. (2000). Effects of a brief motivational interview with college student drinkers. Journal of Counseling and Clinical Psycholom, 68, Brown, R. A., Ramsey, S. E., &Sales, S. (1998). Therapist manual: MI+ interventiun. Unpublished training manual. Burke, B. L., Arkowitz, H., & Dunn, C. (2002). The efficacy of motivational interviewing and its adaptations: What we know so far. In W. R. Miller & S. Rollnick (Eds.), Motivational interviewing: Preparing people to change addictive behavior (2nd ed., pp ). New York: Guilford Press. 54 Journal of College Counseling = Spring 2003 Volume 6

10 Centers for Disease Control and Prevention. (1998). State-specific prevalence among adults of current cigarette smoking and smokeless tobacco use and per capita tax-paid sales of cigarettes: United States, Morbundity and Mortality Weektv Reports, 47, Centers for Disease Control and Prevention. (2000). Trends in cigarette smoking among high school students: United States, Murbundity and Mortality Weekly Repurts, 49, Colby, S. M., Barnett, N. P., Monti, P. M., Rohsenow, D. J., Weissman, K., Spirito, A,, et al. ( 1998). Brief motivational interviewing in a hospital setting for adolescent smoking: A preliminary study. Journal of Counseling and Clinical PsychuluJy, 66, Lawendowski, L. A. ( 1998). A motivational intervention for adolescent smokers. Preventive Medicine, 27, A39-A46. Marlatt, A. G., Baer, J. S., Kivlahan, D. R., Dimeff, L. A., Larimer, M. E., Quigley A., et al. (1998). Screening and brief intervention for higli-risk college student drinkers: Results from a 2-year follow-up assessment. Journal r8cunsulting and Clinical l sycholo~, 66, McNeill, A. D. (1991). The development of dependence on smoking in children. British Journal oj dddictiuns, 86, Miller, W. R. (1995). Increasing motivation for change. In R. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp ). Boston: Allyn & Bacon. Miller, W. R., & Rollnick, S. (2002). Motivatiunal interviewing: Preparing people tu change addictive behaviur (2nd ed.). New York: Guilford Press. Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. (1992). Motivatiunal enhancement therapy manual: A clinical researchguide fur therapists treating individuals with alcohol abuse and dependence (Project Match Monograph Series No. 2). Rockville, MD: National Institute of Alcohol Abuse and Alcoholism. Ockene, J. K., Emmons, K. M., Mermelstein, R J., Perkins, K. A., Bonollo, D. S., & Voorhees, C. C., et al. (2000). Relapse and maintenance issues for smoking cessation. Health Psycholojy, 19(Suppl. l), Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In search of how people change: Applications to addictive behaviors. American Psycholo& 47, Prokhorov, A. V., Pallonen, U. E., Fava, J. L., Ding, L., & Niaura, R. (1996). Measuring nicotine dependence among high-risk smokers. Addictive Behaviors, 21, Rollnick, S., Butler, C. C., & Stott, N. (1997). Helping smokers make decisions: The enhancement of brief intervention for general practice. Patient Edtlcation and Cotlnselin,y, 31, Rollnick, S., & Heather, N. (1992). Negotiating behavior change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short readiness to change questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, Schroeder, C. M., & Prenrice, D. A. (1998). Exposing pluralistic ignorance to reduce alcohol use among college students. Journal of Applied Social Psycholom, 28, Wechsler, H., Rigotti, N. A., Gledhill-Hoyt, J., & Lee, H. (199Sj. Increased levels of cigarette use among college students: A cause for national concern. Juurnal of the American Medical Association, 280, Journal ofcol!ege Counseling Spring 2003 Volume 6 55

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