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
5
This talk
• The NHS Centre for Smoking Cessation and
Training
• Establishing behaviour change techniques
required for optimal behavioural support
6
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
intervention content that
directly promotes abstinence
BCTs
Focus on specific behaviour
maximise motivation to
abstain or minimise
motivation to smoke
Address motivation
intervention content that
promotes activities that
indirectly facilitate abstinence
Maximise self-regulation
Promote adjuvant activities
General aspects of interaction
competences necessary for
effective delivery of specific
BCTs and adjuvant activities
promote mental and
physical activities that
either reduce exposure to
motivation to smoke or
help with resisting that
motivation
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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
1Lancaster
& Stead 2005: Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev.
– DH data
• CO verified and self-reported 4 wk quit rates
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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
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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
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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-COverified quit rates
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BCTs suggested by 4 wk quit rates
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
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
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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
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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
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