Nicotine & Nicotine Tobacco Research & Tobacco Research Advance Access published May 17, 2010

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1 Nicotine & Nicotine Tobacco Research & Tobacco Research Advance Access published May 17, 2010 Original Investigation Behavior change techniques used by the English Stop Smoking Services and their associations with short-term quit outcomes Robert West, 1 Asha Walia, 2 Natasha Hyder, 2 Lion Shahab, 1 & Susan Michie 3 1 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 UCL Medical School and Division of Psychology and Language Sciences, University College London, London, UK 3 UCL Medical School and Division of Psychology and Language Sciences, University College London and the NHS Centre for Smoking Cessation and Training, London, UK Corresponding Author: Robert West, 2-16 Torrington Place, London WCI E68T, UK. Telephone: ; robert.west@ucl.ac.uk Received December 21, 2009; accepted April 9, 2010 Abstract Objective: To help identify effective components of behavioral support for smoking cessation, this study identified the behavior change techniques (BCTs) specified in the treatment manuals of 43 English Stop Smoking Services (SSSs) and assessed association between inclusion of specific BCTs and SSS success rates. Methods: SSSs (n = 144) were contacted to request their treatment manuals. BCTs included in the manuals were identified using a previously established taxonomy. Associations between inclusion of specific BCTs and short-term (4-week) quit outcomes were assessed. Results: Ninety-eight services responded, of which 43 had suitable treatment manuals. Out of 43 possible BCTs, SSS manuals included a mean of 22 (range 9 37). The number of sessions used for delivery of the smoking cessation intervention differed markedly (range 1 13) across services. Nine of the BCTs were significantly associated with both self-reported and carbon monoxide (CO)-verified 4-week quit rates (e.g., strengthen ex-smoker identity, provide rewards contingent on abstinence, advise on medication, measure CO) and a further 5 were associated with CO-verified 4-week quit rates but not self-reported quit rates (e.g., advise on/ facilitate use of social support, provide reassurance). SSSs that scheduled in more sessions had higher quit rates. Conclusions: English SSSs vary widely in how far their treatment manuals include specific behavior change techniques and how many do not have manuals. It is possible to identify BCTs that are reliably associated with better quit outcomes. Behavioral support for smoking cessation could be improved by a more systematic approach to identifying and applying BCTs that are associated with better quit outcomes. There is strong evidence that stopping smoking improves health and reduces the risk of premature death (Doll, Peto, Boreham, & Sutherland, 2004; Royal College of Physicians of London, T.A.G., 2000) and that treatment to aid cessation in the form of a combination of behavioral support and medication is effective and highly cost-effective as a life-saving clinical intervention (Parrott, Godfrey, Raw, West, & McNeill, 1998; West, McNeill, & Raw, 2000). In recognition of this, a national network of Stop Smoking Services (SSSs) was introduced in England in 1999 (Department of Health, 1999). The aim was to ensure that every smoker in the country would have access to effective evidence-based behavioral support and medication paid for by taxation through the National Health Service (NHS). The NHS is currently organized around 144 Primary Care Trusts (PCTs), each of which has autonomy to fund, configure, and run its health services under broad guidance from national bodies, such as the National Institute for Clinical and Healthcare Excellence and the Department of Health. This can lead to wide variation in practice. The SSSs are funded and organized by these PCTs. Although use of the SSSs has been shown to considerably increase smokers chances of quitting successfully (Ferguson, Bauld, Chesterman, & Judge, 2005; Judge, Bauld, Chesterman, & Ferguson, 2005), there is wide variation in reported success rates (NHS, 2008). This variation will in part be due to variation in smoker characteristics (Bauld, Chesterman, Judge, Pound, & Coleman, 2003) but may also result from variation in delivery of the services. Three aspects of delivery may be important: (a) how the intervention is delivered, that is, the style, mode, and context; (b) who delivers it, that is, whether it is a nurse, pharmacist, psychologist, etc.; and (c) what is delivered, that is, the behavior change techniques (BCTs) and/or medication used or the content of the program. This paper focuses on the BCTs that are used in the program while recognizing that other aspects of the service are also important areas for research. In order to investigate the association between content of behavior change interventions and outcome, one needs a reliable method to describe content (Michie & Abraham, 2004). Methods for specifying content by reliable taxonomies of component BCTs have been developed in relation to physical activity doi: /ntr/ntq074 The Author Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. 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2 BCTs and smoking cessation and healthy eating (Abraham & Michie, 2008), as well as smoking (Michie, Hyder, Walia, & West, 2010). This study applied the smoking taxonomy (Michie et al., 2010) to identify the BCTs used in individual behavioral support in English SSSs and investigate associations with 4-week quit outcomes. This taxonomy was developed from two key source documents, which it was expected would contain all or almost all of the BCTs likely to be used in behavioral support for smoking cessation (McEwen, 2008; McEwen, Hajek, McRobbie, & West, 2006). This taxonomy had resulted in 43 BCTs being identified that could be reliably coded from written description of components of behavioral support. It is an empirical question as to how far each of them is worthwhile including in treatment programs. The study used the treatment manuals from the SSSs as the source of the BCTs. Treatment manuals are usually written by local service managers based on whatever training and guidance they might have received. Clearly, there may be a significant gap between what is specified in these manuals and what may occur in practice, but to the extent that the manuals acted as a guide to the behavioral support provided, it may be possible to detect an association between inclusion of specific BCTs and success rates despite this noise. The taxonomy of BCTs used in this study can be linked to a broad theory of motivation, PRIME Theory, that has been elaborated in the context of smoking cessation (West, 2009). A key tenet of this theory is that behavior at each moment arises from the strongest of competing impulses and inhibitions at that moment and that these arise from multiple sources, including unlearned and learned stimulus impulse associations (instinct and habit) and feelings of anticipated pleasure, satisfaction, or relief (wants and needs), which can be driven by past associations and by positive and negative evaluations (beliefs about what is good and bad), which in turn are often driven by preformed plans (self-conscious intentions). Self-control is required for deliberate behavior change, and this involves generating sufficiently strong wants and needs from self-conscious intentions to overcome competing sources of motivation at every relevant moment. Self-control is effortful and requires and depletes mental resources. Therefore, the main challenge in sustaining behavior change involves (a) addressing motivation by minimizing the frequency and strength of momentary impulses to engage in the old behavior and maximizing the want or need to sustain the new behavior pattern, for example, by fostering identity change and (b) maximizing the self-regulatory capacity and skills needed to achieve this, for example, by advising on ways of conserving mental resources (West). BCTs may act directly on these mechanisms or act indirectly by (c) promoting adjuvant activities, for example, taking smoking cessation medication and (d) supporting the other BCTs, for example, by establishing rapport. It is of interest to determine to what extent BCTs that are effective in aiding smoking cessation fall into these different functional categories. Guideline documents recommend use of multiple sessions of behavioral support, and there is some evidence that more sessions may result in higher success rates (U.S. Department of Health and Human Services, 2008). However, individual randomized controlled trials have not clearly shown this (Lancaster & Stead, 2005a). The present study provided an opportunity to examine whether specifying more behavioral support sessions in service treatment manuals is associated with higher success rates. Guidance documents in the United Kingdom recommend seven sessions to allow for sessions before the quit date that enable medication to be acquired and started if necessary and up to four weeks of sessions after the quit date covering the period when most withdrawal symptoms are at their worst (McEwen et al., 2006). This study formed part of a program of research carried out by the National Health Service Centre for Smoking Cessation and Training, the goal of which is to establish what constitutes best practice in treatment to aid smoking cessation and the competences required of stop smoking specialists, and to develop and implement assessment and training to ensure that all specialists possess those competences (see Methods All 144 SSSs in England at the time of the study were contacted on up to six occasions and requested to send their treatment manuals for individual behavioral support. The request specified that they should send any documents that provided guidance or instructions on the content of the interactions with smokers. Manuals were assessed as to whether they contained sufficient detail to identify BCTs; this was done by two researchers independently, with 100% agreement. The taxonomy developed by Michie et al. (2010) was used to identify and categorize the BCTs mentioned within each manual. The number of sessions specified by each manual for the delivery of the intervention was also recorded. The number of times each of the 43 BCTs was mentioned in each manual and the number of different BCTs included in the manual were recorded. Outcome data for each SSS were obtained from published figures for the year in which the treatment manuals were provided ( ). Each SSS is required to provide to the Department of Health the number of smokers setting a quit date with the service and the 4-week quit outcomes separately for men and women using self-reported abstinence with and without carbon monoxide (CO) verification. The self-reported 4-week quit outcome consisted of a claim by the client not to have smoked at all for the 2 weeks prior to this point: that is, there is a 2-week grace period immediately after the quit date during which slips are allowed. It is recognized that short-term outcome data of this kind do not translate directly into long-term abstinence, but there are now sufficient data to be able to make robust projections (Ferguson et al., 2005; Hughes, Keely, & Naud, 2004). On average, smokers who remain abstinent at 4 weeks have a 30% chance of remaining abstinent for 12 months, and 12-month abstainers have a 70% chance of remaining abstinent permanently (Etter & Stapleton, 2006). Our primary outcome measure was CO-verified abstinence at 4 weeks; however, because CO verification is not undertaken by some SSSs as they lack effective systems to ensure that this is done, we also report self-reported abstinence. Self-reported success rates in the English SSSs are typically higher than CO-verified rates. This is partly because, as noted, not all SSSs have adequate systems for measuring CO, partly because smokers who are abstinent are unwilling or unable to attend for CO measurement and partly because some smokers report that they are abstinent when they are not. It is not practicable to collect long-term abstinence data from all smokers 2

3 Nicotine & Tobacco Research receiving behavioral support in the English SSSs because the resources required to achieve a useful follow-up rate would be prohibitive. Some SSSs also provide a group-based service for about 3% of smokers, and data are not available to exclude this group. Although these reporting errors will undermine the capacity to detect associations with BCTs, the large sample (177,064 smokers recorded as having set a quit date) provides a reasonable prospect that the effect of errors in outcome reporting will be substantially mitigated. Means, SD, and ranges of the numbers of sessions and the numbers of different BCTs used by each SSS were calculated. The proportion of SSS treatment manuals that incorporated each BCT was also calculated. Associations between number of times a given BCT was mentioned in a treatment manual with success rates were estimated using logistic regression with the complex samples procedure in SPSS. This performs a multilevel logistic regression in which SEs are adjusted for clustering within PCTs, taking account of gender as a stratum. Results Of the 144 English SSSs, 98 (68%) responded (Figure 1). Of these, 72 (50% of the total) had treatment manuals, but only 43 (30% of the total) contained guidance on BCTs for individual behavioral support. The mean number of sessions identified in the manuals was 5.8 (median = 6; range 1 13; SD = 2.2). The number of BCTs identified in the manuals ranged from 9 to 37 (median = 23) out of a possible 43. The mean number of BCTs was 22.1 (SD = 6.9). Table 1 shows for each BCT the percentage of SSSs that included the BCT in its treatment manual. Ninety-eight percent (42/43) of SSSs included facilitate action planning, facilitate goal setting, and advise on stop smoking medication (Table 1). The next most commonly included BCTs were measure CO (95%), elicit client views (88%), assess current readiness and ability to quit (86%), ask about experience of stop smoking medication... (86%), and facilitate relapse prevention and coping (86%). The least commonly mentioned BCTs were set graded tasks and use reflective listening (both 5%). Service reorganization meant that six services that had supplied treatment manuals no longer existed in the same form at the end of the year for which outcome data were available, leaving 37 services providing treatment manuals with available outcome data. For nine BCTs, the number of times it was cited in the treatment manuals was associated with both CO-verified and self-reported 4-week abstinence rates, and for a further five, there was an association with CO-verified abstinence rates only (see Table 1). These included BCTs serving all four major functions, for example, strengthen ex-smoker identity (addressing motivation), advise on changing routine (maximizing self-regulation), advise on medication (promoting adjuvant activities), and elicit and answer questions (general support for other BCTs). Even where the associations were not significant, in 70 out of 86 cases, they were positive, and in only one case was there a significant negative association ( use reflective listening ). There was a clear association between the number of sessions scheduled in the treatment manual and the success rates of the SSS for both COverified and self-reported outcomes. There were no gender differences in associations between BCTs and success rates. Discussion To our knowledge, this is the first systematic analysis of BCTs used by SSSs in any country. The English services are probably the best-established national services and have provided a blueprint for many other countries. The results show that there is wide variation in terms of both whether they have treatment manuals and what BCTs are included in those manuals. There is also wide variation in the number of sessions provided. There was reliable evidence of associations between many of the BCTs specified in the manuals and quit outcomes and between the number of scheduled sessions and quit outcomes. The findings provide a starting point for establishing best practice in smoking cessation behavioral support. The application of a reliable coding system for treatment manuals offers the prospect of being able to arrive at systematic descriptions of behavioral support, which then provides a potential basis for investigating which BCTs are best adopted in what settings. Some of the BCTs found to be associated with quit outcomes clearly accord with other sources of evidence. For example, medication has been clearly shown to aid cessation, and it is to be expected that directing stop smoking specialists to give advice on medication would be helpful. Meta-analyses of RCTs have suggested that teaching skills to combat temptations to smoke are helpful (U.S. Department of Health and Human Services, 2008), and the present analysis supports this. Other BCTs found by this study to be associated with quit outcomes merit further investigation in experimental studies, including giving advice on changing routines and on conserving mental resources and particularly on fostering an ex-smoker identity. It is widely believed that CO measurement has motivational potential, but this is the first study to find a clear association with quit outcomes, albeit in a nonexperimental design. Figure 1. manuals. The numbers of services providing suitable treatment The breadth of BCT functions that are associated with higher abstinence rates supports the use of broadly based models of behavior change that encompass concepts of enduring motivation, the personal rules that people adopt when attempting to change behavior, self-regulatory capacity, issues of identity, and pharmacological interventions that influence physiological 3

4 BCTs and smoking cessation Table 1. Prevalence of BCTs used by English Stop Smoking Services (SSSs) and association with quit outcomes Percentage of SSSs Odds ratio (95% CI), level of significance Behavior change techniques including BCT in treatment manual CO verified Self-report Effect present for both outcomes 1. Strengthen ex-smoker identity (M) ( ), < ( ), < Elicit client views (G) ( ), < ( ), Measure CO (M) ( ), ( ), < Give options for additional and later support (A) ( ), ( ), Provide rewards contingent on successfully ( ), ( ), stopping smoking (M) 6. Advise on changing routine (S) ( ), ( ), < Facilitate relapse prevention and coping (S) ( ), ( ), Ask about experiences of stop smoking medication ( ), ( ), <0.001 that the smoker is using (A) 9. Advise on stop smoking medication (A) ( ), ( ), Association with either outcome 10. Advise on conserving mental resources (S) ( ), ( ), Advise on/facilitate use of social support (A) ( ), ( ), Summarize information/confirm client decisions (G) ( ), ( ), Provide reassurance (G) ( ), ( ), Boost motivation and self-efficacy (M) ( ), ( ), Provide information on withdrawal symptoms (G) ( ), ( ), < Explain the purpose of CO monitoring (G) ( ), ( ), < Use reflective listening (G) ( ), ( ), No association with either outcome 18. Adopt appropriate local procedures to enable ( ), ( ), clients to obtain free medication (A) 19. Advise on avoidance of social cues for smoking (S) ( ), ( ), Advise on environmental restructuring (S) ( ), ( ), Assess current and past smoking behavior (G) ( ), ( ), Assess current readiness and ability to quit (G) ( ), ( ), Assess past history of quit attempts (G) ( ), ( ), Assess withdrawal symptoms (G) ( ), ( ), Build general rapport (G) ( ), ( ), Elicit and answer questions (G) ( ), ( ), Emphasize choice (G) ( ), ( ), Explain expectations regarding treatment program (G) ( ), ( ), Explain the importance of abrupt cessation (S) ( ), ( ), Facilitate action planning/help identify lapse triggers (S) ( ), ( ), Facilitate barrier identification and problem solving (S) ( ), ( ), Facilitate goal setting (S) ( ), ( ), Identify reasons for wanting and not wanting ( ), ( ), to stop smoking (M) 34. Offer/direct toward appropriate written materials (A) ( ), ( ), Prompt commitment from the client there and then (M) ( ), ( ), Prompt review of goals (S) ( ), ( ), Prompt self-recording (S) ( ), ( ), Provide feedback on current behavior (M) ( ), ( ), Provide information on consequences of , ( ), ( ), smoking and smoking cessation (M) 40. Provide normative information about others ( ), ( ), behavior and experiences (M) 41. Provide rewards contingent on effort or progress (M) ( ), ( ), Set graded tasks (S) ( ), ( ), Tailor interaction appropriately (G) ( ), ( ), Number of sessions 1.10 ( ) ( ), Note. A = target adjuvant activities; BCTs = behavior change techniques; G = provide general support for other BCTs; M = target motivation; S = target self-regulatory capacity and skills. Predictor variable in logistic regressions was number of times the BCT in question was mentioned in the treatment manual. 4

5 Nicotine & Tobacco Research drivers of need. To date, PRIME Theory appears to be the only attempt thus far to capture this breadth in a single model (West, 2009). It is noteworthy that such a broad range of BCTs has emerged in the field of smoking cessation without obvious theoretical underpinning; this suggests that clinical experience has led those designing interventions in the direction of broadly based implicit theories. There were a number of limitations to this study. One is the use of treatment manuals rather than records of actual practice as source data for the BCTs. Clearly, it cannot be assumed that the BCTs specified in the manuals are delivered in practice (Lichstein, Riedel, & Grieve, 1994) or, conversely, that they are not delivered if they are not mentioned in the manuals. This would serve to weaken associations we observed with outcomes. For example, BCTs providing general support (e.g., build general rapport ) may be delivered without being specified in treatment manuals. It may also be that some BCTs are more easily implemented than others. Future research should assess the delivery of manual-specified BCTs in practice by audiotaping or videotaping and coding SSS intervention sessions (Bellg et al., 2004). Alternatively, service providers or clients could complete process evaluation forms or behavior checklists, although these methods are less reliable correlates of what actually happens in sessions (Bellg et al.). Possible factors mediating manual fidelity, such as experience, skills and training levels of service providers, and SSS funding levels, also need to be investigated. Notwithstanding these issues, the treatment manual is the starting point for training and delivery of behavioral support, and associations between what is included in the manual and outcomes should inform what is included in future manuals. A second limitation is that variation in characteristics of SSSs and their clients could add noise to the outcome data and undermine associations with BCTs. It is also theoretically possible that characteristics of the SSSs or their clients could underlay associations found between BCTs and success rates. However, it is difficult to conceive of characteristics that would lead to the specific pattern of associations found which some BCTs clearly showing associations with success rates and others not. Many of the BCTs were highly correlated with each other and so it was not possible to disentangle independent contributions in a multiple logistic regression. In addition, a multiple logistic regression approach is limited in that some of the BCTs are logically dependent on each other and may therefore operate in clusters (e.g., advising on use of medication and ask about experiences of medication). Research is needed into how BCTs cluster in principle and in practice, and with sufficient data, it may become possible to determine how different clusters operate and how they are associated with outcomes. There is evidence that the best way to increase implementation of guidelines is by rewriting guidelines in behaviorally specific terms (Michie & Johnston, 2004). The taxonomy used here may help SSS manual designers in doing this. The national recommendations for timing and frequency of BCT use during the SSS intervention also need to be defined, as it may not be just what is delivered but also when (e.g., during prequit, quit date, or postquit sessions) and how often it is delivered that is important. Manual content may also vary because of regional characteristics. It is well known that factors such as service characteristics and area economic deprivation levels are related to the outcomes of SSSs (Bauld et al., 2003). Demographic characteristics, such as gender, age, and ethnicity, have also been shown to be crucial to intervention effectiveness (Albarracin et al., 2005). Thus, certain population characteristics may also lead to variation in manual content, as services may tailor their intervention content to the specific groups of people they cater for in their area. There are already SSSs customized for certain groups, such as pregnant women, mothers, and those under 16 years of age. There is some evidence for the increased effectiveness of interventions tailored for specific population groups (Noar, Benac, & Harris, 2007), as well as for individual smokers (Kreuter, Strecher, & Glassman, 1999; Lancaster & Stead, 2005b; Strecher, 1999). Thus, the reasons for and impact of variation need to be investigated further. Overall, the findings provide the first snapshot of BCTs used by a major national smoking cessation support program and associations between these and quit outcomes. This picture will need to be revised in the light of new evidence, but it provides a starting point for refining guidelines and identifying competences necessary to be a stop smoking specialist. In relation to refining guidelines, there are now grounds for placing greater emphasis on some BCTs than others. Similarly, when it comes to assessing and training stop smoking specialists, we have the beginnings of an evidence base that can be used to target those activities. Funding Cancer Research UK and the U.K. Department of Health provided funding for the study. The research is also affiliated with the UK Centre for Tobacco Control Studies. 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 with regard to those competences. LS has received an honorarium as well as hospitality from Pfizer. Acknowledgments We would like to thank Adam Evans and Freyja Haudur for their assistance in coding manuals. References Abraham, C., & Michie, S. (2008). A taxonomy of behavior change techniques used in interventions. Health Psychology, 27, Albarracin, D., Gillette, J. C., Earl, A. N., Glasman, L. R., Durantini, M. R., & Ho, M. H. (2005). A test of major 5

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