Optimising behavioural support in smoking cessation

1
Optimising behavioural support in smoking
cessation
Robert West and Susan Michie
Professors of Health Psychology University
College London
2
This talk

• The English Stop Smoking Services
• The NHS Centre for Smoking Cessation and Training
• Establishing competences required for optimal
  behavioural support
• Next steps

3
This talk

• The English Stop Smoking Services
• The NHS Centre for Smoking Cessation and Training
• Establishing competences required for optimal
  behavioural support
• Next steps

4
What are the NHS Stop Smoking Services?

• 144 local services each serving an average
  population of 60,000 smokers
• Providing a programme of behavioural support and
  medication to smokers wanting help with stopping
• Free of charge (apart from small prescription
  charge in some cases)
• Funded from general taxation, part of the
  National Health Service
• Group and individual sessions held in GP
  practices, health centres, pharmacies or other
  local facilities
• Stop smoking advisors are mainly professions
  allied to medicine (e.g. nurses, psychologists,
  pharmacists)

5
Why were they set up?

• In 1997 the incoming Labour government recognised
  that treating cigarette addiction falls within
  the remit of the NHS because
• Smoking is the largest cause of premature death
  and social gradient in life-expectancy
• Most smokers are addicted to cigarettes
• Cigarette addiction is a treatable condition
• The treatment prevents premature death with an
  average cost per QALY of about 1000
• One of the cheapest way of saving lives in
  healthcare

6
What should the behavioural support look like?

• Pre-quit assessment session
• Quit date session
• Post-quit sessions - usually weekly for at least
  4 weeks

Sessions should last at least 30 minutes
7
What is impact of behavioural support?

• Impact reach x effectiveness
• Reach
• 650,000 (7.5) smokers per year
• Effectiveness
• 33 CO-verified quit at 4 weeks
• 7 expected to quit permanently
• 4 would have quit with medication alone
• 3 quit permanently because of behavioural
  support
• Impact
• 19,500 permanent ex-smokers created per year in
  England by behavioural support

8
What is the cost per quitter?

• Total cost of behavioural support
• 73 million
• Number of quitters
• 217,000 CO-verified 4-week quitters
• 19,500 permanent ex-smokers created
• Cost per quitter
• 337 per 4-week quitter
• 3744 per permanent ex-smoker created

9
Trends in performance since 2004
10
Variation in performance across local services
Data from individual services in North of England
11
Conclusion

• The English Stop Smoking Services were set up to
  save lives cheaply by treating cigarette
  addiction
• They have succeeded
• But there is a wide variation in performance and
  success rates could and should be higher
• Success rates are declining as numbers treated
  are rising

12
This talk

• The English Stop Smoking Services
• The NHS Centre for Smoking Cessation and Training
• Establishing competences required for optimal
  behavioural support
• Next steps

13
Aims of the NCSCT

• Establish what are the most effective behaviour
  change techniques used to help smokers to stop
• Use these to determine competences required by
  stop smoking specialists, managers and
  commissioners
• Develop and implement
• assessment tool for these competences
• procedure for certification
• Develop and implement training and continuing
  professional development to ensure all staff
  possess these competences

14
NCSCT website
15
This talk

• The English Stop Smoking Services
• The NHS Centre for Smoking Cessation and Training
• Establishing competences required for optimal
  behavioural support
• Next steps

16
Three steps

• Develop a reliable method of identifying
  behaviour change techniques (BCTs)
• Establish which of these have the strongest
  evidence base to support them
• Identify competences required to deliver
  effective behavioural support

17
1. Identifying BCTs

• Method
• Apply pre-existing taxonomy of BCTs1 for other
  behaviours (e.g. exercise) to key smoking
  cessation guidance documents
• Add smoking-specific BCTs as necessary
• Check reliability
• Results
• 43 BCTs for individual behavioural support
• 15 BCTs for group-based support
• gt86 agreement between coders differences easily
  resolved through discussion

1Abraham Michie (2008) Health Psychology 27
379-387
18
Classification of BCTs by function
19
2. Establish which techniques are effective

• For individual behavioural support ...
• Two sources of evidence to identify BCTs
• that are mentioned in more than one report of an
  effective intervention in Cochrane reviews of
  RCTs
• in treatment manuals of local services that are
  consistently associated with higher success rates

Each method has strengths and limitations
20
BCTs used in effective behavioural support
interventions

• Searched Cochrane review1 of individual
  behavioural support to identify interventions
  shown to be effective
• plt0.05 compared with control condition
• Odds ratio 1.5
• Four of the 21 interventions met these criteria
• Identified BCTs reported in 2 effective
  interventions

1Lancaster Stead 2005 Individual behavioural
counselling for smoking cessation. Cochrane
Database Syst Rev.
21
BCTs used in effective behavioural support
interventions

• Searched Cochrane review of individual
  behavioural support to identify interventions
  shown to be effective
• plt0.05 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
22
BCTs in effective behavioural support
interventions from RCTs

• Provide information on consequences of smoking
  and smoking cessation
• Prompt commitment from the client there and then
• Facilitate barrier identification and problem
  solving
• Facilitate relapse prevention and coping
• Facilitate action planning/know how to help
  identify relapse triggers
• Facilitate goal setting
• Measure CO
• Advise on methods of weight control
• Teach relaxation techniques

• Advise on stop-smoking medication
• Give options for additional and later support
• Assess current and past smoking behaviour
• Assess current readiness and ability to quit
• Assess past history of quit attempts
• Assess physiological and mental functioning
• Assess number of contacts who smoke
• Offer/direct towards appropriate written
  materials
• Provide information on withdrawal symptoms

23
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
  plt0.01 in all four tests identified

24
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
  plt0.01 in all four tests identified

Lack data on delivery Lack of variation may mask
effects
25
Behaviour change techniques associated with
higher success rates

• Barrier identification problem solving
• Change routine
• Measure CO
• Provide advice on conserving resources
• Relapse prevention and coping planning
• Give client options of additional or later
  support
• Strengthen ex-smoker identity
• Enquire about medication
• Elicit client views
• Summarise information confirm client decisions
• Provide rewards contingent on successfully
  stopping smoking

• Boost motivation and self efficacy
• Provide rewards contingent on effort towards
  stopping smoking
• Explain the purpose of CO monitoring
• Provide information on positive and negative
  consequences of behaviour
• Goal setting
• Provide advice and information about medication
• Enquire about withdrawal symptoms
• Provide information on withdrawal symptoms

26
BCTs supported by both types of evidence

• Provide information on consequences of smoking
  and smoking cessation
• Measure CO
• Facilitate barrier identification and problem
  solving
• Facilitate relapse prevention and coping
• Facilitate goal setting
• Advise on stop-smoking medication
• Give options for additional and later support
• Provide information on withdrawal symptoms

27
... categorised by function

• Motivation
• Provide information on consequences of smoking
  and smoking cessation
• Measure CO
• Self-regulation
• Facilitate barrier identification and problem
  solving
• Facilitate relapse prevention and coping
• Facilitate goal setting
• Adjuvant activities
• Advise on stop-smoking medication
• Give options for additional and later support
• General role
• Provide information on withdrawal symptoms

28
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

29
Conclusion

• It is possible to reliably identify a set of BCTs
  used in behavioural support for smoking cessation
• 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

30
This talk

• The English Stop Smoking Services
• The NHS Centre for Smoking Cessation and Training
• Establishing competences required for optimal
  behavioural support
• Next steps

31
Research

• Carry out the same analysis for group-based
  behavioural support
• Refine and add to list of BCTs
• Collect further evidence on effectiveness

32
Practice

• Develop competence-based assessment and training
• Inform development of services in England
• Collaborate with international partners to
  develop evidence-based services, assessment and
  training internationally

33
Acknowledgements

• The team
• Sue Churchill
• Asha Walia
• Natasha Hyder
• Andy McEwen
• Nicky Willis

• Funding
• Department of Health
• Cancer Research UK

www.ncsct.co.uk