Development of a taxonomy of behaviour change techniques used in individual behavioural support for smoking cessation
Research Highlights
► Behavioral support for smoking cessation can be characterised by BCTs. ► Forty three such BCTs have been identified. ► These BCTs form a taxonomy, classified into four functions. ► This taxonomy can be reliably applied to specifying BCTs in treatment protocols and reports.
Introduction
Treatment to aid smoking cessation, involving a combination of ‘behavioural support’ and medication, is available in many countries (Raw, McNeill, & Murray, 2010) and has been found in randomised controlled trials to be both effective and cost-effective (US Department of Health and Human Services, 2008, West et al., 2000). Behavioural support takes the form of advice, discussion, encouragement and activities designed to help quit attempts to succeed. Unfortunately there has been no evidence of improvements in effectiveness of behavioural support over the past 20 years (Lancaster and Stead, 2005, Stead and Lancaster, 2005). A major barrier to progress has been a lack of a systematic system for labelling the specific behaviour change techniques (BCTs) in the packages that have been evaluated and so no way of establishing which BCTs are most effective. This study attempted for the first time to develop a taxonomy of BCTs used in behavioural support for smoking cessation that could be reliably applied to treatment manuals. This would provide the first step in determining which components of behaviour support packages are most effective singly or in combination and ultimately to the development of more effective interventions.
Guidance documents for reporting intervention trials (for example, CONSORT (Moher, Schulz, & Altman, 2001) and TREND statements (Des Jarlais, Lyles, & Crepaz, 2004)) call for details of interventions to be given; however, there is no consensus about what details, or how these should be expressed. The importance of using a reliable method with standardised language and detailed BCT descriptions to specify, design and evaluate behavioural interventions has been highlighted by the recent UK Medical Research Council guidance for developing and evaluating complex interventions (Craig et al., 2008).
The lack of a reliable taxonomy of BCTs for smoking cessation is not just hampering advances in treatment; it is also a barrier to effective delivery of behavioural support in practice. Without it, we do not have a basis for specifying what stop smoking practitioners should be doing in their sessions with clients. This means that we do not know what to include in clinical treatment manuals nor do we have a sound basis for specifying the competences required by stop smoking practitioners. This is increasingly an issue as behavioural support for smoking cessation is becoming more widely available worldwide. In the UK, the behavioural support element of the treatment is free, open to all and usually delivered in a series of weekly individual or group sessions (McNeill, Raw, Whybrow, & Bailey, 2005) (Raw et al., 2009a, Raw et al., 2009b). There are some 600,000 quit attempts recorded using the English Stop Smoking Services (SSSs) and reported success rates are broadly in line with what would be expected from randomised controlled trials (NHS, 2008). However, there is considerable variability in success rates (NHS, 2008) and it is not known what behaviour change techniques (BCTs) are used by the SSSs or which are most effective in helping smokers to stop. The same would be expected to be true for other stop smoking treatment programmes in other countries though data are not generally available.
Taxonomies of BCTs have been developed for health interventions other than smoking cessation. For example, Hardeman, Griffin, Johnston, Kinmonth, and Wareham (2000) identified 19 BCTs from interventions designed to prevent weight gain, such as, “self monitoring”, “using graded tasks” and “use of prompts or cues”. Inoue et al. (2003) described the content of interventions to increase physical activity in terms of specific BCTs such as “goal setting”, “discussing benefits, costs and barriers”, and “positive self talk”. Similarly, Conn, Valentine, and Cooper (2002) identified 20 specific BCTs, such as “relapse prevention”, “self monitoring”, and “social support”, in a meta-analysis of interventions designed to increase physical activity (Semaan et al., 2002). Albarracin et al. (2005) carried out a meta-analysis of 354 HIV-prevention interventions and reliably identified 10 distinct techniques, such as, “condom use skills training”, “providing factual information”, and “attitudinal arguments”. A reliable and generalisable taxonomy of 26 distinct BCTs has been developed for interventions to increase physical activity and healthy eating, with detailed definitions and a manual to guide the identification of BCTs (Abraham & Michie, 2008). This taxonomy was used as the basis for the one developed in the present study.
It is likely that the taxonomy developed for diet and physical activity interventions would need to be supplemented by BCTs specific to smoking cessation. Guidance documents in this area refer to discussing clients' experiences including difficulties encountered, giving encouragement and support, carbon-monoxide (CO) monitoring, advising on techniques for coping with urges to smoke, and relapse prevention strategies (Raw, McNeill, & West, 1998)(US Department of Health and Human Services, 2008). Therefore, the new taxonomy should include such elements, albeit described in consistent and specific terms.
It is important to have a coherent theoretical basis for any BCT taxonomy. We decided to use the PRIME Theory of motivation for this purpose because it appears to be the only one that accommodates in a single model the different contributions to behaviour made by direct stimulus–impulse associations, drive states, past experiences of pleasure and relief from discomfort, beliefs about what is good or bad, self-conscious intentions and how these arise from associative learning, exposure to social and other cues, communication and identity: all of these seeming to be important in smoking behaviour and needing to be addressed in helping smokers to stop (West, 2009). Under this model, the goal of behavioural support is to change the balance of impulses and inhibitions by reducing impulses to smoke and increasing motivation and capacity to resist those impulses on all relevant occasions. This involves 1) minimising motivation to smoke, for example by challenging beliefs about the benefits of smoking, 2) maximising motivation not to smoke, for example by keeping the reasons for stopping salient, 3) maximising skills and capacity for self-control, for example by avoiding tempting situations and 4) optimising use of stop-smoking medications. This can be achieved in many different ways. These include: helping people to make appropriate plans; changing beliefs about what is good or bad; changing biological drivers of want or need to engage in the behaviour; and changing exposure to stimuli that trigger the impulse to engage in the behaviour. The empirical question to be addressed in this paper is whether such a functional higher order classification of BCTs can be reliably applied.
This study formed the first part of a programme of research carried out by England's National Centre for Smoking Cessation and Training (NCSCT), 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 www.ncsct.co.uk).
Section snippets
Method
Ethical approval was given by University College London Psychology Department Ethics Committee: BSC/2008/9/009.
As a starting point, two key source documents were identified by the authors which it was expected would encompass most if not all the main BCTs that would be likely to be used (McEwen, 2008, McEwen et al., 2006). These were analysed by coders (NH and AW) in terms of component BCTs. BCTs were defined as “any explicit description of intervention content that can alter a participants'
Results
Analysis of the guidance documents yielded 43 BCTs. Twelve BCTs were similar to those identified in physical activity and healthy eating interventions (Abraham & Michie, 2008). The final set of BCT labels and descriptions is shown in Table 1. The inter-rater reliability (Table 2) for identifying BCTs in treatment manuals for the 28 manuals examined ranged from r = 0.65 to 0.96 with a mean value of 0.84 (SD = 0.086) and percentage agreement ranged from 86% to 95%. Reliability was equally high with
Discussion
A taxonomy of behaviour change techniques used for individual behavioural support for smoking cessation was developed and it was found that it could be used reliably to code the treatment manuals of SSSs in England. A higher-order functional classification was also developed and this could be reliably applied to the BCTs.
Twelve of the BCTs in the present taxonomy were the same as those for interventions to increase physical activity and healthy eating (Abraham & Michie, 2008) suggesting that it
Conflict of Interest Statement
N Hyder and A Walia have no conflicts of interest. R West undertakes consultancy and research for and receives travel funds and hospitality from manufacturers of smoking cessation medications and has a share of a patent for a novel nicotine delivery device. R West and S Michie are co-directors of the NHS Centre for Smoking Cessation and Training.
Acknowledgements
Our thanks to Dr. Andy McEwen for giving expert advice and to Adam Evans and Freyja Hauður for the help in reliability testing. The study was partly funded by Cancer Research UK and partly funded by the UK Department of Health through the NHS Centre for Smoking Cessation and Training.
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