After two days of celebration and reflection in Kansas City with over 150 of our quitline colleagues, it only seems fitting to close this series of blog posts, Celebrating 20 Years of Quitline History with 20 Questions About our Future, with a laser-like focus on the ultimate reason we all do this work: to help people quit tobacco. To help us do that, NAQC asked David Abrams, PhD, Executive Director of The Schroeder Institute for Tobacco Research and Policy Studies for his thoughts on THE POTENTIAL OF QUITLINES AND CESSATION SERVICES TO DECREASE TOBACCO USE PREVALENCE IN THIS DECADE. Here is what Dr. Abrams had to say.

There is a great potential to save lives, reduce preventable death and disability burden, and save hundreds of millions to billions of dollars in health care expenses over the next decade. As has been stated by many leaders many times before, making this potential a reality is a matter of putting what we know into practice and policy in a coordinated fashion. This challenge is what myself and others have called "systems integration.” By systems integration I refer to the need for: (a) strong unwavering political will to support comprehensive tobacco control; (b) putting in place aligned incentives and resources at every level of the system - individual, group, organizational, community, state and national; and (c) full implementation of evidence-based tobacco control that is comprehensive, has continuity of coordinated care, and includes supportive policies at every level of health care and public health service delivery. Thus systems integration is "arguably the single most critical missing ingredient”, referred to in the Institute of Medicine’s (2007) recommendations for "Ending The Tobacco Problem: A Blueprint For The Nation” ^1,3 and outlined in the Department of Health and Human Services’ government-wide coordinated effort, "Tobacco Control Strategic Plan for the Nation” (November, 2010).

The preservation of both the Affordable Care Act by the Supreme Court and hopefully of some of the prevention fund, contain resources and an extraordinary opportunity to achieve dramatic gains in cessation if they are not eviscerated. These resources must be fought for and preserved with all our might. Already they have been eroded and threaten our goals if we are to achieve the unrealized potential for significant reductions in population tobacco use prevalence.

Another dream for the future is to address the huge connection between tobacco use disparities and general health disparities. The disparity gap in smoking prevalence is huge and may be widening. Lower socioeconomic status smokers, those with mental health or substance abuse disorders and other vulnerable populations including racial and ethnic minorities, Native Americans, LGBT, and others, continue to smoke at rates that exceed 30% and can be as high as 70-85%, whereas many higher SES groups smoke at rates that are under 10%. Tobacco use disparities are a very strong driver of health disparities and thus eliminating tobacco use will go a long way to eliminating health disparities in our nation. In the next decade our intervention programs must do a better job of reaching, treating and supporting those at disproportionate risk. We must stop blaming the victims (calling them hard to reach, hard to treat, unmotivated, non-adherent or non- compliant with treatment recommendations). If we are to make a difference in the next decade we must take full responsibility for finding ways to reach and treat all our smokers with accessible and affordable evidence-based interventions at every level of society.

Clearly, to significantly accelerate the stalled reduction in tobacco use prevalence and eliminate the devastating deaths, disease burden and cost to society, requires having interventions with both broad reach and with levels of intensity and tailoring that can be matched to the needs of different groups in a stepped care model.² This dream of a plausible and possible future has been around for decades and perhaps it can indeed be realized in the coming decade. This would clearly make a huge difference in health impact and reducing the snails pace, slow rates of reduction in population prevalence that we have seen in the last decade, hovering around 20%.

Evidence-based interventions like quitlines and other proven brief and self-help interventions (used by health professionals, such as the three or five A’s, and Internet programs) are cost-efficient, have capacity to be scalable to reach and serve large numbers of consumers and can be combined or used together. They also must be able to adjust relatively fast in response to changing consumer demand. These valuable moderate intensity resources, that lie in the "sweet spot” between more intensive and more costly interventions and very minimal, less costly but less effective materials (e.g., educational brochures left on tables in worksites or doctors’ offices) are essential, central drivers of any future hope to make a significant impact at the population level in the next decade. Making a difference at the population level requires large numbers of users to stop and remain non-users. But once a user is driven to a moderate intensity intervention, additional challenges exist to boosting future sustained cessation rates. These moderate to low intensity programs are good, but of course can be improved in terms of treatment efficacy and especially in addressing relapse prevention, which is still very high in almost all forms of treatment of addictions and is a great challenge for the future.

Quitlines and evidence-based Internet programs are at the heart of this capacity to make a difference at the population level, are increasingly integrated, and employ cognitive-behavioral, pharmacological and social support as core components. Evidence is mounting that combined quitline and Internet programs can make a very cost efficient impact on population health if fully implemented at capacity. A recent study of Internet and combined Internet plus quitline counseling indicated 30-day point prevalence abstinence rates at 18-months follow up of 17 to almost 20 percent.⁹ If scaled up to national capacity such a program might ideally reach 10 million smokers each year producing almost 2 million new ex-smokers.

Policies that encourage cessation can dramatically increase reach, such as raising taxes, enforcement of indoor air laws and media campaigns. After the federal tax on tobacco increased by $0.62 in April 2009, many quitlines experienced a surge in call volume; nationally, over 550,000 calls were received through 800-QUIT-NOW in the first five months of 2009 compared to 592,000 in the 2008 calendar year.⁴ More recently, CDC’s national tobacco education campaign yielded about 200,000 additional calls to state quitlines over a 12-week period.⁵

For some users who are unable to sustain tobacco-free lifestyles, more intensive, costly and specialized stepped up care programs are also needed. Such intensive programs will have more limited reach, but may also be integrated with health care and public health services to provide highly specialized care, for example in the context of hospital inpatient and outpatient treatments for medical conditions that are exacerbated by tobacco use behavior (e.g. cancer, cardiovascular, pulmonary disease and many others), mental health and substance abuse disorders and clinics that serve the under- or uninsured and those who find it difficult to access state-of-the-science programs. Such intensive programs can also partner with quitlines and Internet programs, providing additional support and ability to prevent relapse as needed and at times when access to an inpatient, outpatient, primary care office or community program is not possible.

The bottom line is that several forces ideally should come together in a coordinated fashion to optimize reductions in smoking prevalence, reinvigorating the slowed rate of reduction in smoking prevalence of the past decade. To increase impact at the population level, it is a matter of reach multiplied by the effectiveness of treatment for those reached in a cost efficient manner.^2,3 Quitlines play a central role in this equation as they are capable of cost-efficient delivery. Increasingly their integration with other modes of intervention such as health care and worksite settings, the Internet, over-the-counter pharmacotherapy, smart phones, and new applications such as text messaging and interactive voice response make quitlines the backbone of an increasing array of efficient and cost-effective modes of access and delivery.

It is quite complicated to decide how best to allocate resources to optimize these goals and computer simulation modeling can help us examine several "what if” scenarios to help us allocate resources. Such programs have increased in sophistication in recent years and have also been improved because we have better data to use as inputs and predict transitions. One such model, SimSmoke, developed by Dr. David Levy has been around for over two decades now and has been used across the world to examine how policies and interventions at different levels of reach, efficacy and cost efficiency, can be combined to accelerate population prevalence reduction. In a series of simulation studies of plausible futures, models that include ideal implementation of comprehensive interventions and policies might boost the stalled reductions in population prevalence in surprisingly optimistic ways if fully implemented.^6,7 We have shown that reaching a Healthy People goal of 12% smoking prevalence could be achieved before 2020 by boosting the number of smokers who make quit attempts and by increasing the impact of quitlines and other cessation services.^3,8 Increasing the number of people that make quit attempts, encouraging those who fail to make more frequent quit attempts without delay, and reducing relapse rates among those that do make an attempt, are three critical ways that the SimSmoke modeling shows to dramatically boost future reductions in smoking prevalence and the concomitant deaths, disease burden and dollar costs in our nation.

Putting everything we know into practice and policy in an integrated system of comprehensive interventions and policies can make a dramatic difference in the next decade. The question is, can we create the political will to make the right thing to do the easy thing to do, from a social justice perspective?

References

1. Abrams DB. Comprehensive smoking cessation policy for all smokers: systems integration to save lives and money. In: Bonnie RJ, Stratton K, Wallace RB, (eds). Ending the tobacco problem: a blueprint for the nation. Institute of Medicine. Washington: The National Academies Press, 2007.

2. Abrams DB, Orleans CT, Niaura RS, Goldstein MG, Prochaska JO, Velicer W. Integrating individual and public health perspectives for treatment of tobacco: A combined stepped care and matching model. Ann Behav Med. 1996 Fall;18(4):290-304.

3. Abrams DB, Graham AL, Levy DT, Mabry PL, Orleans CT. Boosting Population Quits Through Evidence-Based Cessation Treatment and Policy. Am J Prev Med. 2010 Mar;38(3 Suppl):S351-63. PMID: 20176308.

4. Bailey L. Opening Plenary. NAQC Annual Conference. June 8, 2009. Accessed August 6, 2012 online at http://www.naquitline.org/resource/resmgr/2009_conference_materials/openingplenary.pdf.

5. Centers for Disease Control and Prevention press release. June 14, 2012. Landmark ad campaign yields almost 200,000 more calls to state quitlines after 12 weeks. Accessed August 6, 2012 online http://www.cdc.gov/media/releases/2012/p0614_smoking_quitlines.html/.

6. Levy DT, Mabry PL, Graham AL, Abrams DB, Orleans CT. Modeling the impact of smoking cessation treatment policies on quit rates. Am J Prev Med 2010;38(3S):S364 –S372.

7. Levy DT, Mabry PL, Graham AL, Orleans CT, Abrams DB. Reaching Healthy People 2010

by 2013: a SimSmoke simulation. Am J Prev Med 2010;38(3S):S373–S381.

8. Levy, DT, Graham AL, Mabry PL, Orleans CT, Abrams, DB. Exploring Scenarios to Dramatically Reduce Smoking Prevalence: A Simulation Model of the Three-Part Cessation Process. Am J Public Health. 2010 Jul; 100(7):1253-9. Epub 2010 May 13. PMID: 20466969.

9. Graham AL, Cobb NK, Papandonatos GD, Moreno JL, Kang H, Tinkelman DG, Bock BC, Niaura RS, Abrams DB. A Randomized Trial of Internet and Telephone Treatment for Smoking Cessation. Arch Intern Med. 2011 Jan 10; 171(1):46-53.

With a clear sense of many of the opportunities on the horizon for quitlines, NAQC asked North Carolina’s seasoned tobacco control program manager, Sally Herndon, how do we most effectively leverage quitlines to improve cessation statewide/province-wide? As is the case in most states and provinces, tobacco control in North Carolina (NC) is a team effort. Sally pulled in Director of Tobacco Cessation, Joyce Swetlick, and NC’s Chronic Disease Director, Dr. Ruth Petersen. She also checked in with partners NC Prevention Partners, the NC Alliance for Health and the NC State Health Plan to come up with the following strategies for most effectively leveraging quitlines:

Work with quitline service providers to offer the most effective tobacco cessation services and provide strong documentation about the effectiveness and cost-effectiveness of quitlines. Cessation services through quitlines are customer friendly. Access and availability is much-improved over offering cessation classes, where there may or may not be a ready group at any given time. Quitline services, well managed, can be efficient and effective and a great source of real-time data in this information age!

Help people make the healthy choice, the easy choice. Evidence-based policies such as smoke-free environments and significant increases in tobacco prices through tobacco tax increases help prompt tobacco users to quit while quitlines help these tobacco users to stay quit.

Help clinics make the evidence-based choice, the easy choice. Quitlines are a great resource for busy clinicians. With a fully functioning quitline, busy clinicians can ask, advise, conduct brief counseling to determine readiness and discuss medications, and then refer to the quitline – either via fax or electronically through electronic health records. Expert quitlines then can do the heavy lifting – counseling - which is time consuming. They can get data back to each clinic. Clinics can even have "healthy competitions” to see which ones are doing best in offering this evidence-based service to tobacco users who want to quit. North Carolina’s Community Transformation Grant, led by Dr. Petersen, is a true team effort working to change health care systems to adopt clinical practice guidelines for tobacco cessation (as well as hypertension and cholesterol management). Working through NC’s AHEC Program and Community Care of North Carolina, we seek to create a medical home for all North Carolinians and advance evidence-based clinical practices by incorporating the 5 A’s into electronic health records and usual care.

Bridge these two concepts: promoting evidence based tobacco control policy with evidence-based services to help tobacco users who want to quit. Most tobacco users want to quit so let’s give them both the services they need and supportive community environments. Empower the experts in the white coats and stethoscopes to testify on behalf of their patients in support of evidence-based policies coupled with evidence-based tobacco cessation services.

Encourage clinicians to speak out! Clinics and hospitals that become dependent on quitline services to most efficiently meet clinical practice guidelines and federal regulations can be effective spokespersons for the value of these services to a community. Recently, decision-makers in tight budget times have tried to force a decision: Which is more important, policy change such as smoke-free environments or helping smokers/tobacco users quit? Answer: Both are critically important and go hand-in-glove.

Document and communicate the excess medical care costs of tobacco use and secondhand smoke exposure and the cost effectiveness and cost savings of quitlines to decision-makers, especially to publicly funded programs such as Medicaid and Medicare. In North Carolina, one of the biggest issues for these tight budget times is the cost of medical care. Excess medical care from tobacco use costs the state $2.4 billion each year and $769 million in Medicaid costs – not to mention $293 million in excess medical care costs due to secondhand smoke exposure. (NC Medical Journal Jan/Feb 2011) Quitlines are indeed cost effective and can help reduce these costs. For every dollar spent in FY11, QuitlineNC has provided a $2.55 return on investment.

Invite payers (insurers) and their customers (employers) to benefit from quitline efficiency and effectiveness by contracting to pay for quitline services for members/employees. North Carolina’s State Health Plan (SHP) contracts through the Tobacco Prevention and Control Branch with QuitlineNC, offering services to all state health plan members. Since providing these services through QuitlineNC, significantly more SHP members have enrolled in QuitlineNC services. In the second year, three times more members enrolled in QuitlineNC than before SHP became a fiscal partner. In addition, this cohort had the highest quit rate. The six month responder quit rate at 30-days point prevalence was 41.8% and the intent to treat rate was 21.1%.

Partner with those who serve highest risk. For example, QuitlineNC has become an important part of the effort to make all NC mental hospitals and substance abuse facilities 100% tobacco free. We learned that inpatients prefer tobacco cessation counseling from clinic staff, so we trained mental health and substance abuse staff in tobacco cessation and they make referrals to the quitline at discharge to help their patients who are very high risk stay tobacco free once they go back into the community.

Thanks North Carolina team!! How about your state or province? What strategies do you employ to leverage quitlines to improve cessation access and quality?

Okay – so it’s been a while since our last post. Time flies when you’re having fun planning a conference! You may remember that our goal was to explore 20 questions and we are on question number 14. With just weeks to go before we meet in Kansas City, we have four more posts to go! Questions 18, 19 and 20 will be revealed and answered in NAQC’s Vision Café!

For question 14 we turned to Dr. Susan Zbikowski. Dr. Zbikowski is Senior Vice President of Research, Training & Evaluation at Alere Wellbeing and has extensively studied and published and presented research on technology enhanced treatments for tobacco cessation. Specifically we wanted to know her thoughts on ongoing research that is most likely to advance quitlines and the cessation agenda. Thankfully, she had this to share:

Perhaps one of the greatest advancements in the tobacco cessation field in the past two decades is that research demonstrated phone-based counseling was effective. This research and funding that came from the master settlement agreement (as well as other resources) became a catalyst for change – resulting in a proliferation of quitlines in North America. The field needs to continue to innovate and advance. I am greatly concerned about the current trends of exploring less intensive, less effective treatment options. The quitline community needs to decide what it wants to achieve from a research agenda- is the goal to develop more cost effective treatments that can be delivered to more people even if the rate of success if lower? Or is the goal to have a more effective treatment that can produce better outcomes, but potentially with added costs?

I think it is important for the membership to pause, reflect, and prioritize. Below are other topics for consideration.

Should priority populations receive different treatments?

I am often asked by my colleagues and the funders of quitlines if special services (i.e., targeted protocols) should be delivered to priority populations such as ethnic minorities, individuals with chronic medical conditions, LGBT individuals, individuals with mental health concerns, and other groups. I would say that quitline services should not be changed until there is clear evidence that the results are lower than expected. There is a difference between delivering culturally appropriate services and targeted protocols. While many of these groups/ populations experience health disparities, more research is needed to evaluate the reach and effectiveness of quitlines with these groups before developing and delivering new interventions. This can be readily achieved if states or national organizations provide funding to evaluate outcomes with large enough samples

We need to improve the number of people using assistance when quitting.

We should celebrate the fact that quitlines are the most widely used publically funded/available treatment. Approximately 10% of all tobacco users have used a quitline at some time. But we can do better. I continue to be amazed by the statistic that the majority of tobacco users try to quit without assistance and that most will fail. Tobacco control leaders have the opportunity to advance the field by focusing on this population- those who attempt to quit without assistance. More work is needed to improve awareness of effective treatments and the availability of more funding to support demand. This alone can have a large public health benefit. The recent CDC-sponsored national tobacco education campaign is proof that demand could be increased.

We may be neglecting another population.

A new priority population may be emerging- non-daily smokers. Recent research suggests that nearly 25-30% of US adult smokers are non-daily smokers, yet use of quitlines among this population is quite low. Although this population doesn’t smoke as much as daily smokers, research has shown they are dependent on tobacco and may struggle with quitting. Research is needed to increase awareness and use of quitlines among this population. Be sure to join the semi-facilitated networking session on this topic at the conference! Bring data to share if you have it!

Stop diluting treatments, but continue to study how to effectively design and use novel treatment approaches.

With rare exceptions, interventions typically are successful with 25% of tobacco users. There is a need to examine novel approaches to treatment. While many new treatment modalities have emerged in recent years (web, text), none of these approaches achieve outcomes that are superior to phone-based or in person treatments. Thus, more research is needed to determine how these approaches can be most effectively combined with other treatments and/or matched to subsets of tobacco users to achieve better outcomes.

Are we ready for the aging population of smokers?

Cigarette smoking poses substantial health risks at any age, but smoking is particularly dangerous for older smokers, who are at greater risk of cardiovascular disease, respiratory conditions, and cancer. There are 3.8 million smokers aged 65+ (a 9.5% smoking rate). With the population of older adults expected to double by 2050, the total absolute number of older adult smokers is expected to rise substantially; presenting a significant public health problem. Late last year, my colleagues and I conducted a systematic review of the literature on effective treatment for older adult smokers (Zbikowski et al., 2012, Maturitas). While our review supports intervening with older smokers to aid cessation we were somewhat surprised that quit rates from these studies and the relative effectiveness of different intervention approaches (e.g., behavioral, medication, provider) were no different than the general literature on smoking cessation. This is concerning due to the health consequences of continued smoking for this population. Thus, significant opportunities for innovation and improvement remain.

Understanding the state of research funding in the U.S.

It is more difficult than ever to get research funded. Pay lines have declined over the past decade. Typically only studies in the top 7^th percentile or better are funded. Researchers have fewer opportunities to apply for funding as well- a specific grant idea/application can only be submitted twice rather than three times as in the past. And, nearly 50% of applications are rejected without being scored. Lastly, researchers have to propose incredibly novel studies ("Innovation” is a NIH requirement) in order to secure funding. While novel interventions should benefit the quitline community; it is not that simple. For example, subtle variations on previously conducted research or approaches to optimize or improve upon existing treatment are often not seen as novel. In addition, while NIH is seeking novelty they appear less willing to take risks on funding large studies without proof of concept, acceptability of treatment, developed treatments, and proof of initial efficacy. I am concerned about the ability to advance a quitline research agenda without devoted funding coming from sources other than NIH.

In keeping with our focus on quitlines and systems change, NAQC thought it would be wise to check in with Rob Adsit, MEd, Director of Education and Outreach at the University of Wisconsin School of Medicine and Public Health, Center for Tobacco Research and Intervention. Rob has been focusing on supporting systems change, outreach and education to Wisconsin hospitals and health systems for quite some time and we thought he would have some words of wisdom about how the quitline community can move most effectively from fax-referral to e-referral and what the benefits of such a change would be. Guess what? He did! Here is what Rob had to share with us:

In the quickly changing landscape of healthcare in the United States, the morbidity and mortality from tobacco use remains relatively constant. Great strides are being made in the adoption of electronic health records (EHR) over the last several years, yet healthcare systems, including clinics and hospitals, are not consistently identifying and treating their patients who use tobacco. In fact, while 70% of smokers visit a primary care clinician annually, and 80% of smokers report wanting to quit, only 25% of tobacco-users leave their primary care visit with an evidence-based tobacco dependence treatment intervention. The electronic health record, the adoption of which is being accelerated by healthcare reform and meaningful use as defined in The American Recovery and Reinvestment Act of 2009, is ripe with potential to dramatically increase the identification and evidence-based treatment of tobacco users in the United States. This promise, in large part, relies not only on building evidence-based tobacco dependence treatment into the EHR, but also on incorporating the evidence-based, brief tobacco dependence treatment intervention into the roles and workflow of outpatient as well as inpatient clinicians.

Assisting healthcare systems transition from paper fax referrals to digitized, fully electronic referrals directly from the EHR is important for two reasons. The first is that over the next several years the majority of healthcare delivery systems will have or will transition to electronic health records. This will mean a paper referral form that needs to be faxed from a clinic or hospital to a tobacco quitline will be an outlier in a digitized, electronic world. And, a treatment outcome that is faxed back to a clinic or hospital via paper will have to be manually entered into a patient’s electronic record, which will be a low priority for staff in an electronic health record environment. The second important reason for moving to referrals from the EHR is the ability to help healthcare systems achieve and document meaningful use of EHRs. Identification and treatment of patients who use tobacco is core to meaningful use, and referring patients to tobacco quitlines can help healthcare providers achieve this important measure.

The transition will be challenging. It is time and cost intensive to develop electronic health record mechanisms, functionality and interfaces. It also requires expertise and a vocabulary that many of us do not yet possess, and are quickly trying to learn and understand. In addition, we cannot do this work alone. To be successful, it requires a partnership of health information technology, public health, healthcare systems, and quitlines to design, develop, build, test and implement electronic referrals directly from EHRs to tobacco quitlines and, equally important, treatment outcome data from tobacco quitlines back into patient EHRs. This closed loop is a vital component to referrals from the EHR as clinicians are reluctant to refer patients to external services if they do not receive information about the outcome of that referral.

Several states are exploring, developing and testing, or have already developed, mechanisms to refer patients to tobacco quitlines directly from electronic health records – Kentucky, Massachusetts, New Hampshire, Oklahoma, Texas, and Wisconsin.

With the NAQC Conference right around the corner, you might think about trying to connect with your quitline colleagues from these states to learn more about their work on fully electronic, bi-directional referrals from health systems to the quitline!

Thanks, Stephen! Now that we have had some discussion about all of the things that make a quit coach great, let’s move to their training. As Stephen mentioned in his blog post, there is a laundry list of things that must be addressed and emphasized in the training of quit coaches. To give us her thoughts on the most critical aspects of training for quit coaches, NAQC checked in with Donna Czukar, Senior Director of Support Programs at the Ontario Division of the Canadian Cancer Society. Here is what Donna had to say:

This could be called one of those "it depends” answers. Because, really, successful training addresses many elements and much depends on the individuals, the environment, and the trainers. Let’s look at some key points:

• Recruitment and selection of coaches: hiring individuals who have the required skills and experience is significant. However, those who also demonstrate commitment and passion for helping others will inspire the team and maintain a vitality that will be great for the services being offered.

• Content: theory, information, client type, protocols, database and other system elements form a knowledge base required by all to do the job. They need to be taught, studied, reviewed and importantly, combined to offer an evidence-based accountable service where people will feel welcome and motivated to pursue their cessation goals.
  
  
• Individualism: while all coaches need to achieve the competencies required of the position, they will come with different strengths and will have a variety of learning styles. Recognizing this early on will help the trainer identify how best to adapt their material and modes of delivery to maximize both efficiency and effectiveness of training.
  
  
• Environment and "osmosis”: learning from other team members is valuable particularly when the environment is positive and collaborative. Mentoring can be consciously built into the training process so that help is both offered and available on request. However, coaches will hear the tone and tactics used by others in counseling and can be encouraged to incorporate helpful elements of these into their conversations. This "osmosis” can have a significant impact on development and performance.
  
  
• Practice, practice, practice: nothing compares with actually doing the job. Multitasking takes time to perfect. Role-playing provides opportunities to work through and prepare for possible scenarios. Call shadowing is a great way to hear how callers present and how coaches respond. Taping calls and reviewing with a colleague or supervisor allows for listening to a complete interaction while also stopping and repeating sections to zero in on specific items to discuss. Composing online comments and having them read by someone else before posting will identify concerns before going "live.” These strategies will help someone feel very prepared for the actual experience of providing cessation support.
  
  
• CQI: being a quit coach needs ongoing attention to skills and delivery. During and beyond training, self-reflection and debriefing with supervisors and colleagues should be encouraged. Having a strong team where coaches and trainers are motivated toward individual performance and service goals takes continuous dedication and effort – and produces excellent results.

Now back to the original question, "what is the ‘most’ critical aspect of training?” The answer may still be "it depends.” It is truly all important, but involves many elements, the criticality of which is situational and reliant on having comprehensive approaches and strategies to pull it all together to achieve the best outcomes for all involved.

What are the critical elements of your training to coaches? Have you found that the approach to training in your organization has changed over time? If so, why?