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

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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
• gt86 agreement between coders differences easily
  resolved through discussion
• BCTs categorised according to functions in
  changing behaviour
• gt90 agreement

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Classification of BCTs by function
intervention content that directly promotes
abstinence
maximise motivation to abstain or minimise
motivation to smoke
intervention content that promotes activities
that indirectly facilitate abstinence
promote mental and physical activities that
either reduce exposure to motivation to smoke or
help with resisting that motivation
competences necessary for effective delivery
of specific BCTs and adjuvant activities
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... categorised by function

• Motivation
• e.g. Provide information on consequences of
  smoking and smoking cessation
• Self-regulation
• e.g. Facilitate barrier identification and
  problem solving
• Adjuvant activities
• e.g. Advise on stop-smoking medication
• 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
• 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
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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
• plt0.05 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
• 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
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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
  plt0.01 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