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Behavior Change Techniques Used in Group-Based Behavioral Support by the English Stop-Smoking Services and Preliminary Assessment of Association with Short-term Quit Outcomes
Robert West, B.Sc., Ph.D.,1 Adam Evans, B.Sc.,2 & Susan Michie, B.A., M.Phil., D.Phil.3
Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London and the NHS Centre for Smoking Cessation and Training, London, UK 2 Department of Psychology, University of Surrey, Guildford, UK 3 UCL Division of Psychology and Language Sciences, University College London and the NHS Centre for Smoking Cessation and Training, London, UK
1
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Corresponding Author: Robert West, Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London and the NHS Centre for Smoking Cessation and Training, 216 Torrington Place, London WC1E 6BT, London, UK. E-mail: robertwest100@gmail.com Received November 20, 2010; accepted May 9, 2011
Abstract
Objective: To develop a reliable coding scheme for com ponents of group-based behavioral support for smoking cessation, to establish the frequency of inclusion in English Stop-Smoking Service (SSS) treatment manuals of specific components, and to investigate the associations between inclusion of behavior change techniques (BCTs) and service success rates. Methods: A taxonomy of BCTs specific to group-based behavioral support was developed and reliability of use assessed. All English SSSs (n = 145) were contacted to request their groupsupport treatment manuals. BCTs included in the manuals were identified using this taxonomy. Associations between inclusion of specific BCTs and short-term (4-week) self-reported quit outcomes were assessed. Results: Fourteen group-support BCTs were identified with >90% agreement between coders. One hundred and seven services responded to the request for group-support manuals of which 30 had suitable documents. On average, 7 BCTs were included in each manual. Two were positively associated with 4-week quit rates: communicate group member identities and a betting game (a financial deposit that is lost if a stop-smoking buddy relapses). Conclusion: It is possible to reliably code group-specific BCTs for smoking cessation. Fourteen such techniques are present in guideline documents of which 2 appear to be associated with higher short-term self-reported quit rates when included in treatment manuals of English SSSs.
Introduction
Treatment to aid cessation, in the form of a combination of behavioral support and medication, is effective and highly costeffective as a life-saving clinical intervention (Parrott, Godfrey, Raw, West, & McNeill, 1998; U.S. Department of Health and Human Services, 2008; West, McNeill, & Raw, 2000). A national network of Stop-Smoking Services (SSSs) providing this treatment was introduced in England in 1999 (Department of Health, 1999). The National Health Service (NHS) is currently organized around 145 primary care trusts (PCTs; though the number changes frequently with merging and splitting), each of which has autonomy to fund and configure its health services under general guidance from national bodies, such as the National Institute for Clinical and Healthcare Excellence and the Department of Health. This autonomy can lead to wide variation in practice. The SSSs are funded and organized by these PCTs. Although use of NHS SSSs generally increases smokers chances of quitting (Ferguson, Bauld, Chesterman, & Judge, 2005; Judge, Bauld, Chesterman, & Ferguson, 2005), success rates vary considerably. This will be due in part to variation in smoker characteristics and reporting practices (Bauld, Chesterman, Judge, Pound, & Coleman, 2003) but may also result from variation in delivery of the services. We recently reported that inclusion of specific behavior change techniques (BCTs) in treatment manuals for individual behavioral support could account for a significant proportion of the variance (West, Walia, Hyder, Shahab, & Michie, 2010). A significant proportion of treatment in the United Kingdom and globally is provided in groups, so it is important to know what BCTs are used in groupbased behavioral support and whether any associations can be
doi: 10.1093/ntr/ntr120 The Author 2011. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
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Methods
Two smoking cessation guidance documents (Hajek, 2010; McEwen, Hajek, McRobbie, & West, 2006) were analyzed by two coders into group-specific BCTs. The approach adopted was similar to that previously used for individual support (Abraham & Michie, 2008; West et al., 2010). A group-specific BCT was defined as any explicit description of intervention content that can alter a participants smoking behavior, which can only be conducted in a group context. These occur alongside
was the PCT, and the dependent variable was success rate of that PCT. The set of BCTs found to be associated with higher success rates was then entered into a forward stepwise multiple regression to determine any independent contribution. Using only one datapoint per SSS is a conservative analysis, but data were not available to enable us to undertake the analysis using individual outcome data from clients.
Results
Agreement between the two coders was 95.3% for the first pilot sample, 92.4% for the second pilot sample, and 94.2% for the combined pilot samples. Cohens kappa coefficients were .74 for both pilot samples and when combined (p < .001 in all cases). The final taxonomy of group-specific BCTs contained 14 categories. The mean number of BCTs identified in each manual was 7.16 (range: 112; SD = 3.45).
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Manuals suitable for coding with quit rate data available (n= 30, 20.7%)
Figure 1. Flowchart of the response rate and inclusion criteria for analysis. Percentages are of the total number of primary care trusts contacted.
Percentage agreement between coders and a weighted kappa were calculated to assess IRR. The proportion of SSS manuals that incorporated each BCT was calculated. The success rates of SSSs (i.e., the percentage of smokers who were 4-week successes) that included or did not include each BCT were compared by analysis of variance. Note that the unit of analysis
Of the 107 (73.8%) SSSs who responded to the request for treatment manuals, 67 (62.6% of the total) ran group sessions (from government statistics, the total nationally at the time was 104), but only 30 (20.7% of the total) had a manual suitable for coding and had outcome data available (Figure 1). The mean number of sessions identified in the manuals was 6.6 (range: 58; SD = 0.65). Table 1 shows for each BCT the percentage of SSSs that included the BCT in its manual. Encourage group discussion (93.3%), Communicate group member identities (80%), and
Table 1.The Number of Manuals Each BCT Appeared in and the Mean (SD) Percentage Success Rate Where They Were Present or Absent
BCT 1. Screen for suitability for group support 2. Explain group support 3. Communicate group member identities 4. Use furniture to reinforce group interaction 5. Encourage comparison of cabon monoxide readings 6. Report on missing members 7. Emphasize each individual has a responsibility for the group 8. Encourage mutual support 9. Group tasks that promote interaction and/or bonding 10. Encourage group discussion 11. Implement buddy system 12. Betting game (placing a financial deposit which is lost if a stop smoking buddy relapses) 13. Public promise 14. Discuss maintenance support Number of manuals Mean (SD) percent 4-week Mean (SD) percent 4-week p Value for difference in BCT appeared in (%) quitters when BCT present quitters when BCT absent mean percent success 14 (46.7) 22 (73.3) 24 (80.0) 5 (16.7) 0 (0) 9 (30.0) 11 (36.7) 23 (76.7) 20 (66.7) 28 (93.3) 16 (53.3) 7 (23.3) 60 (10.9) 62 (8.3) 62 (9.8) 58 (9.4) a 64 (10.4) 61 (11.1) 59 (10.5) 63 (10.2) 64 (10.2) 67 (6.1) 61 (10.7) 57 (15.4) 53 (10.7) 61 (10.9) 59 (10.6) 60 (10.6) 64 (11.2) 55 (9.8) 57 (10.1) 58 (10.8) .81 .28 .04 .61 .27 .77 .38 .05
.07 .04
18 (60.0) 18 (60.0)
63 (8.3) 59 (11.1)
57 (13.0) 63 (9.5)
.15 .24
Note. BCT = behavior change technique. a No comparison made when fewer than 10% or more than 90% of services used the BCT.
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Discussion
The results showed that it was possible to devise a taxonomy that could be used reliably to classify group-specific BCTs contained in manuals for behavioral support to assist with smoking cessation. Fourteen such BCTs were identified. Of these, communicating group member identities and a betting game could be shown to be associated with higher success rates. While the former featured in 80% of treatment manuals, the latter featured in only 23%. This is first time, to our knowledge, that an attempt has been made to systematically identify the components of groupbased behavioral support for smoking cessation. The fact that it can be done reliably potentially provides a basis for examining variation in practice, establishing training programs, and assessing associations with outcomes. The study had a number of limitations, and the findings must be considered preliminary. First, the fact that only 30 of 104 services that provided group treatment provided usable treatment manuals raises the possibility that these were unrepresentative. However, the self-reported 4-week success rates in these 30 were very similar to the national average (60% vs. 61%). Second, it is possible that some services would have continued group support beyond 4 weeks, which might affect longer term outcomes. However, to use data beyond that point would have led to confounding of treatment duration. The treatment process is such that after the first week of abstinence, the group sessions follow the same format so that introduction of some of the BCTs after the 4th week would not have occurred. Third, the findings relating to success rates relied on self-report data, which were recorded by the treatment provider, and we cannot rule out that BCTs may have raised the deception rate rather than the true quit rate. Fourth, the power to detect associations between BCTs and outcome was low with a sample size of only 30 services. A 5th limitation is that we initially identified BCTs using two manuals that formed the basis for treatment recommendations in the United Kingdom; we are not aware of any other such manuals in the United Kingdom. We also added further BCTs that emerged during the examination of individual service treatment manuals. However, there may be other BCTs in use in other countries not identified by this process. This
Supplementary Material
Supplementary Material can be found online at http://www.ntr. oxfordjournals.org
Funding
This work was supported by Cancer Research UK and the UK Department of Health.
Declaration of Interests
RW undertakes research and consultancy for companies that develop and manufacture smoking cessation medications. He also has a share of a patent for a novel nicotine delivery device and is a trustee of QUIT, a charity that provides stop-smoking support. He and SM are codirectors of the NHS Centre for Smoking Cessation and Training, a Department of Health-funded centre whose role is to identify competences necessary for behavioral support for smoking cessation and assess, and train staff in, those competences.
Acknowledgments
We would like to thank Zoe Stavri for her assistance in coding the BCTs and Peter Hajek and Andy McEwen for their feedback on the taxonomy.
References
Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychology, 27, 379387. doi:10.1037/0278-6133.27.3.379 Bauld, L., Chesterman, J., Judge, K., Pound, E., & Coleman, T. (2003). Impact of United Kingdom National Health Service smoking cessation services: Variations in outcomes in England. Tobacco Control, 12, 296301. doi:10.1136/tc.12.3.296
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