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What does it take to be an effective stop smoking specialist?

Robert West

Professor of Health Psychology

University College London

UKCTCS, NCSCT

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This talk

• The NHS Centre for Smoking Cessation and Training

• Establishing behaviour change techniques required for optimal behavioural support

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This talk

• The NHS Centre for Smoking Cessation and Training

• Establishing behaviour change techniques required for optimal behavioural support

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Aims of the NCSCT

• Establish what are the most effective behaviour change techniques to help smokers to stop

• Use these to determine competences required by stop smoking specialists, managers and commissioners of services

• Develop and implement– method of assessing these competences– procedure for certifying competent specialists

• Develop and implement training and continuing professional development to ensure all staff possess these competences

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NCSCT website

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This talk

• The NHS Centre for Smoking Cessation and Training

• Establishing behaviour change techniques required for optimal behavioural support

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Three steps

1. Develop a reliable method of identifying behaviour change techniques (BCTs)

2. Establish which of these have the strongest evidence base to support them

3. Identify competences required to deliver effective behavioural support

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1. Identifying BCTs

• Method

– Apply pre-existing taxonomy of BCTs1 for other behaviours (physical activity and healthy eating) to key smoking cessation guidance documents

1Abraham & Michie (2008) Health Psychology 27: 379-387

– Add smoking-specific BCTs as necessary

– Check reliability by applying the smoking cessation taxonomy to the manuals of 43 Stop Smoking Services

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Results

• 43 BCTs for individual behavioural support

• >86% agreement between coders; differences easily resolved through discussion

• BCTs categorised according to functions in changing behaviour– >90% agreement

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Classification of BCTs by function

BCTs

Focus on specific behaviour

Promote adjuvant activities

Address motivation

Maximise self-regulation

General aspects of interaction

intervention content that

directly promotes abstinence

maximise motivation to abstain or minimise motivation to smoke

promote mental and physical activities that either reduce exposure to motivation to smoke or help with resisting that motivation

intervention content that promotes activities that indirectly facilitate abstinence

competences necessary for effective delivery of specific BCTs and adjuvant activities

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... categorised by function

1. Motivation– e.g. Provide information on consequences of smoking

and smoking cessation

2. Self-regulation– e.g. Facilitate barrier identification and problem solving

3. Adjuvant activities– e.g. Advise on stop-smoking medication

4. General role– e.g. Provide information on withdrawal symptoms

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2. Establish which techniques are effective

• Two sources of evidence to identify BCTs:1. that are mentioned in more than one report of an

effective intervention in Cochrane reviews of RCTs

2. in treatment manuals of local services that are consistently associated with higher success rates

Each method has strengths and limitations

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Development of a list of competences for delivering BCTs

• From national and international guidance documents– Identify recommended BCTs and more general competences

• Identify BCTs used in interventions with evidence of effectiveness– From DH 4 wk quit data– From RCTs in Cochrane review1

• Derive a set of core competences– broad agreement in source documents AND evidence-based

• Classify in terms of – focus on skill versus knowledge and – their function in supporting smoking cessation

1 Lancaster & Stead 2005: Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev.

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Criteria for (a) breadth of support and (b) evidence of effectiveness

• Breadth of support– Mentioned in at least 2 of the 10 expert identified

guidance documents

• Evidence of effectiveness– RCTs

• p<0.05 compared with control condition• Odds ratio ≥1.5

– DH data• CO verified and self-reported 4 wk quit rates

1Lancaster & Stead 2005: Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev.

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BCTs identified in guidance documents and supported by RCT evidence

• Provide information on the consequences of smoking and smoking cessation

• Provide information on withdrawal symptoms

• Facilitate barrier identification and problem solving

• Facilitate relapse prevention and coping

• Facilitate action planning/ identify relapse triggers

• Facilitate goal setting• Measure CO

• Advise on stop-smoking medication

• Assess current and past smoking behavior

• Assess current readiness and ability to quit

• Assess past history of quit attempts

• Offer appropriate written materials

• Prompt commitment from the client there and then

• Give options for additional and later support

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BCTs used in effective behavioural support interventions

• Searched Cochrane review of individual behavioural support to identify interventions shown to be effective:– p<0.05 compared with control condition– Odds ratio ≥1.5

• Identified BCTs reported in ≥2 effective interventions

Poor reporting of BCTs in published articles

Many possible confounding factors

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BCTs associated with higher success rates in Stop Smoking Services

• BCTs used by each of 37 English Stop Smoking Services identified from treatment manuals (6 PCTs had changed and could not be used)

• Data for one month quit rates: 2008-2009– 177064 smokers

• Associations between BCTs and quit rates investigated using multi-level logistic regression taking account of clustering within PCTs

• Repeated for both CO-verified and non-CO-verified quit rates

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BCTs suggested by 4 wk quit rates

Additional 5 identified• Strengthen ex-smoker identity• Elicit client views• Provide rewards on stopping

smoking• Advise on changing routine• Ask about experiences of

stop smoking medication

4 of 14 identified in RCTs supported:

• Facilitate relapse prevention and coping

• Measure CO• Advise on stop-smoking

medication• Give options for additional and

later support

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BCTs associated with higher success rates in Stop Smoking Services

• BCTs used by each of 43 English Stop Smoking Services identified from treatment manuals

• Data for one month quit rates: 2008-2009– 177064 smokers

• Associations between BCTs and quit rates investigated in four replications– Self-report and CO-validated rates– Men and women

• Techniques associated with higher quit rates at p<0.01 in all four tests identified

Lack data on delivery

Lack of variation may mask effects

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Similar approach taken for identifying group BCTs

Those mentioned in at least 2 guidance documents and supported in at least 2 RCTs:

• Encourage group discussions• Encourage group tasks that promote interaction

and/or bonding• Encourage mutual support

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3. Competences to deliver effective behavioural support

• These BCTs form part of a wider set of competences needed to deliver behavioural support

• Consulted 10 international guidance documents and identified additional competences. E.g.– general communication– information gathering– professionalism

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Conclusion

• It is possible to use a reliable taxonomy to examine the frequency of BCTs recommended for practice across guidance manuals

• These can be reliably classified according to their function– e.g. addressing motivation, maximising self-regulatory capacity

• It is possible to identify a subset that have an evidence base in terms of being part of effective behavioural support interventions

• These can be used to develop a core set of competences that all stop smoking specialists should have

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Acknowledgements

The team• Sue Churchill• Fabiana Lorencatto• Asha Walia• Natasha Hyder• Adam Evans• Andy McEwen• Nicky Willis

Funding• Department of Health• Cancer Research UK

www.ncsct.co.uk