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 • >86% 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: • p<0.05 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: • p<0.05 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. 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 BCTs in effective behavioural support interventions from RCTs

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 p<0.01 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 p<0.01 in all four tests identified Lack data on delivery Lack of variation may mask effects

25. 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 Behaviour change techniques associated with higher success rates

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. The team Sue Churchill Asha Walia Natasha Hyder Andy McEwen Nicky Willis Funding Department of Health Cancer Research UK Acknowledgements www.ncsct.co.uk