Are Psycho Educational Smoking Cessation Interventions

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Copyright The British Psychological SocietyReproduction in any form (including the internet) is prohibited without prior permission from the Society

Are psychoeducational smoking cessationinterventions for coronary heart disease patientseffective? Meta-analysis of interventions

M. Huttunen-Lenz1*, F. Song1 and F. Poland2

1School of Allied Health Professions, School of Medicine, Health Policy and Practice,University of East Anglia, Norwich, UK

2School of Allied Health Professions, University of East Anglia, Norwich, UK

Purpose. This systematic review aimed to assess the effectiveness of psychoeduca-tional smoking cessation interventions for coronary heart disease (CHD) patients; and

to examine behaviour change techniques used in interventions and their suitability to

change behavioural determinants.

Methods. Multiple bibliographic databases and references of retrieved articles were

searched for relevant randomized controlled studies. One reviewer extracted and a

second reviewer checked data from included trials. Random effects meta-analyses were

conducted to estimate pooled relative risks for smoking cessation and mortality

outcomes. Behaviour change techniques used and their suitability to change behavioural

determinants were evaluated using a framework by Michie, Johnston, Francis,

Hardeman, and Eccles.

Results. A total of 14 studies were included. Psychoeducational interventions

statistically significantly increased point prevalent (RR 1.44, 95% CI, 1.201.73) and

continuous (RR 1.51, 95% CI, 1.181.93) smoking cessation, and statistically non-

significantly decreased total mortality (RR 0.73, 95% CI, 0.461.15). Included studiesused a mixture of theories in intervention planning. Despite superficial differences,

interventions appear to deploy similar behaviour change techniques, targeted mainly at

motivation and goals, beliefs about capacity, knowledge, and skills.

Conclusions. Psychoeducational smoking cessation interventions appear effective

for patients with CHD. Although questions remain about what characteristics

distinguish an effective intervention, analysis indicates similarities between the

behaviour change techniques used in such interventions.

Alongside well-established medical, pharmacological, and surgical interventions forcoronary heart disease (CHD), patients are also often encouraged to modify their

* Correspondence should be addressed to M. Huttunen-Lenz, Queens Building, University of East Anglia, Norwich NR4 7TJ,UK (e-mail: [email protected]).

The

British

Psychological

Society

749

British Journal of Health Psychology (2010), 15, 749777

q 2010 The British Psychological Society

www.bpsjournals.co.uk


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existing behavioural risk factors such as smoking, lack of exercise, and diet (Isles et al.,2002; NSF-CHD, 2000). However, as changing longstanding habits can be difficult,

psychoeducational interventions have been developed to help in modifying behaviouralrisk factors, but evidence of the effectiveness of such interventions is mixed(Dusseldorp, van Elderen, Maes, Meulman, & Kraaij, 1999; Godin, 1989; Isles et al.,2002; Moore, 1997; Mullen, Mains, & Velez, 1992; NSF-CHD, 2000; Rees, Bennett, West,Davey Smith, & Ebrahim, 2004; Sebregts, Falger, & Bar, 2000). One of factors whichcontributes to contradictions in the body of review evidence appears to be a current

lack of consensus in defining a psychoeducational intervention (e.g., Rees et al., 2004).This makes it more difficult for clinicians to confidently offer practical advice andguidance in planning such interventions.

While a wide range of interventions has been included in earlier reviews of

psychoeducational interventions, these have often omitted smoking cessation-onlyinterventions. When the effectiveness of smoking cessation is considered (Critchley &Capewell, 2003), these interventions can form an important, though specialized, part ofthe secondary prevention and rehabilitation of CHD patients (Isles et al., 2002).Available review evidence suggests that behaviour modification interventions can beeffective in increasing smoking cessation for hospitalized patients in general (Rigotti,Munafo, & Stead, 2007), and for CHD patients (Van Berkel, Boersma, Roos-Hesselink,Erdman, & Simoons, 1999). These reviews, however, have included studies with mixedparticipant populations (Rigotti et al., 2007) and mixed intervention aims (Van Berkel

et al., 1999). Furthermore, available evidence is unclear about identifying thecharacteristics of an effective smoking cessation intervention (Van Berkel et al., 1999), which means that only limited use can be made of the review evidence to develop

practical applications.Michie, Johnston, Francis, Hardeman, and Eccles (2008) suggest that while including

theory may be useful in the design of behaviour change interventions, theory by itselfoffers only limited guidance for designing interventions. Building on their previouswork, which identified theoretical constructs that can be used to explain behaviourchange (Michie & Abraham, 2004), Michie et al. (2008) developed a comprehensive listof behaviour change techniques and a framework of how they link to theoreticalconstructs to be used in intervention planning. Michie and Abraham (2004), identify 11key behavioural constructs, or determinants, namely: social/professional role and

identity; knowledge; skills; beliefs about capabilities; beliefs about consequences;motivation and goals; environmental context and resources; social influences; emotion;action planning; and motivation, attention and decision processes that can be used toexplain behaviour. Behavioural determinants may be influenced by behaviour changetechniques, 137 of which are listed by Michie et al. (2008). Using an initial set of 35behaviour change techniques, researchers independently evaluated techniquessuitability to change each of the behavioural determinants. Depending on the achievedconsensus, behaviour change techniques were rated as agreed use, agreed non-use,disagreement, and uncertain. Agreed use and agreed non-use referred to the

agreement by Michie et al. (2008) on the suitability or non-suitability of a technique toinfluence a behavioural determinant; disagreement meant that this technique hadevaluated both suitable and unsuitable, while uncertain refers to evaluatorsuncertainty about the techniques effectiveness. Michie et al. (2008) intended this

framework to help effective intervention planning by making explicit which behaviourchange techniques are considered effective to change which behavioural determinants.While this framework was initially intended to be used for intervention planning, we

750 M. Huttunen-Lenz et al.


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suggest that it may be applied retrospectively to interventions in meta-analysis, to clarifyintervention features and mechanisms.

As a part of a review of research on psychoeducational cardiac rehabilitationinterventions, the present paper reports findings from our meta-analysis of randomizedtrials of non-pharmacological psychoeducational smoking cessation interventions inCHD patients. We also report our findings from applying the framework by Michie et al.(2008) in retrospectively evaluating behaviour determinants targeted in the studies andtechniques used to change smoking behaviour. We will also discuss issues associated

with difficulties in evaluating psychoeducational interventions and related problemsthat arose in this meta-analysis.

Methods

Identification of studies

We initially searched the Cochrane Controlled Trials Register, PsycINFO, MEDLINE,CINAHL, and Dissertations and Abstracts International databases from the 1970s

onwards to locate any studies that evaluated effectiveness of psychoeducational cardiacrehabilitation interventions using a comparison group design. The search termsincluded words such as myocardial ischemia, rehabilitation, lifestyle, and RCT(randomized controlled trial) (see Table 1 for the MEDLINE search strategy). We also

checked reference lists of previous reviews and retrieved any relevant studies.

Study selection

From initially identified references for research on psychoeducational cardiacrehabilitation interventions, we selected randomized controlled studies of non-pharmacological interventions for smoking cessation among patients with CHD. For astudy to be included, it needed to be written in the English language, to provide data onpoint prevalent smoking cessation, continuous smoking cessation, or mortality as anoutcome and to have a minimum of 6 months follow-up period. While only studieswritten in English were selected for full text review, we recorded the number of studiesexcluded because of the language restriction. One reviewer selected studies for full-text

review based on titles and abstracts and in unclear cases, the opinion of a second

reviewer was sought.

Data extraction

Using data extraction sheetsdesignedfor this review, onereviewer extracted anda secondreviewer checked thedata. Data that wecollectedfrom theprimary studies included studydesign, intervention and patient characteristics, point prevalent (number of non-smokers

at the point of measurement), continuous smoking cessation (number of participants notsmoking during the whole length of follow-up period), and mortality. We contacted allstudy authors after data extraction to request any additional data not published in thearticles. We then included in the analyses, any data obtained from the authors.

Assessment of study quality We assessed the methodological quality of the included studies, covering therandomization process, the intervention and participant description, blinding, outcome

Smoking cessation for CHD patients 751


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verification, and completeness of follow-up. We decided not to rank studies based onthe quality assessment, but recorded weaknesses in the study methodology using thepre-set assessment criteria.

Statistical methods

We collected study results data from all available follow-up time points, but used data atthe longest follow-up, in the main analyses. Relative risk was used as the outcomestatistic to calculate effectiveness of the interventions. We calculated relative risk forthree outcomes: point prevalent, continuous smoking cessation, and total mortality.Point prevalent smoking cessationdescribes the number of participants not smoking at

the measurement point regardless of their previous smoking status, while continuoussmoking cessation describes the number of participants not smoking during the wholelength of the study follow-up. Studies differed in how they reported participants lost

Table 1. MEDLINE search strategy

Limit: English language

1. Myocardial ischemia (medical subject heading (MESH) term, focus, all subheadings)

2. Coronary ADJ3 (adjacent) disease

3. Isch$ ADJ3 disease

4. Cardiovascular disease

5. Myocard$ infarct$

6. Heart attack

7. Heart infarct$8. Angina

9. Coronary artery bypass (MESH, focus, all subheadings)

10. Coronary ADJ3 bypass

11. CABG (Coronary artery bypass graft)

12. PTCA (Percutaneous transluminal coronary angioplasty)

13. Coronary ADJ3 angioplasty

14. Coronary ADJ3 angiograph$

15. Rehabilitation (MESH, focus, all subheadings)

16. Rehabilit$

17. Psychoeducat$

18. Psychoeducat$

19. Health educat$

20. Lifestyle

21. Life ADJ1 style22. Counselling

23. Counselling

24. Health ADJ3 advice

25. Health ADJ1 behav$

26. Cognitive ADJ1 behav$

27. Behav ADJ3 change

28. Behav$ ADJ3 risk

29. Control group

30. Trial

31. Randomized controlled trial

32. RCT

33. Comparison group



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to follow-up. To avoid overestimating intervention effectiveness, we calculated relativerisk so that cases lost to follow-up and deaths were considered as negative outcomes,

i.e., as continuing to smoke. We report the results of the intention-to-treat analysis inthis paper.

For smoking cessation outcomes, a relative risk of larger than one indicated apositive outcome, i.e., that the intervention was successful in increasing smokingabstinence. Relative risk for mortality was calculated so that a value of smaller than oneindicated lower mortality in the intervention group. We carried out sensitivity analyses

to investigate any outlying studies, effects of including two studies which methods ofrandomization was not optimal (Burt et al., 1974; Johnson, Budz, Mackay, & Miller,1999), effects of including one study where we were uncertain about the diagnosis ofsome study participants (Mohiuddin et al., 2007), and effects of including one study

which had both these methodological problems (Bolman, de Vries, & van Breukelen,2002a). RevMan (2008) computer program was used to conduct random effectsmeta-analyses and to graphically present the data. We used Peters method to testfunnel plot asymmetry, which is a regression analysis of association betweentreatment effect and a variable based on sample size (Peters, Sutton, Jones, Abrams, &Rushton, 2006).

Subgroup analyses ( post hoc ) were used to investigate possible causes ofheterogeneity in meta-analysis. In the first subgroup analysis, we investigated theeffects of use of pharmacotherapy in the intervention, firstly with all studies that offered

pharmacotherapy and then with the studies that offered pharmacotherapy only for theintervention group. For pharmacotherapy, we refer to use of bupropion or nicotinereplacement therapy (NRT). The second subgroup analysis investigated effects of

studies explicitly using a theory in intervention planning. For this analysis, we dividedstudies between those that explicitly specified a theoretical model and those that didnot. In the latter group, we included those studies that mentioned behaviour changetechniques. The third subgroup analysis looked at the effects of intervention intensity, in which we classified the interventions as intensive, less intensive, or could beintensive interventions. The intensity of could be intensive interventions wasdependent on participants response to the initial intervention, with the interventioninput increased for those participants who failed to stop smoking or who struggled withstopping altogether after the initial intervention. Finally, we investigated the effect of

follow-up time to intervention effectiveness. For this analysis, we used three data points:up to 6, 12, and 24 months onwards. We conducted statistical tests of interactionbetween independent subgroups (Altman & Bland, 2003).

Evaluation of behavioural determinants and behaviour change techniques

Applying the framework described by Michie et al. (2008) to interventions investigatedin studies, we estimated which behavioural determinants were targeted by theinterventions and which behaviour change techniques appeared to have been used tochange the behavioural determinants. We conducted the evaluation process bycomparing the description of the intervention with the framework of Michie et al.(2008). For example, if the intervention description stated that health care professionalsadvised participants about the health consequences of smoking cessation, we

considered that the targeted behavioural determinant was knowledge and thebehaviour change technique was behavioural information. Finally, based onrecommendations by Michie et al. (2008), we evaluated the suitability of behaviour



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change techniques in relation to targeted behavioural determinants. In this review, theterm agreed technique is used to refer to any technique considered effective by Michie

et al. (2008).

Investigation of process variables

We also investigated process variables reported in the studies. Process variables arecommonly termed mediating variables that can help describe the process through

which, here, change in smoking behaviour happens.

Results

The initial search for psychoeducational cardiac rehabilitation interventions identified8,026 citations, of which 249 were potentially eligible studies and 178 of these appearedto be randomized controlled trials. Twenty of the randomized controlled studies were

identified as potentially eligible smoking cessation studies. We included 11 relevanttrials after scrutinizing the full text articles, and added three additional studies afterinspection of references of retrieved studies and previous reviews. In two cases, thesame study has two published articles (Bolman, de Vries, & van Breukelen, 2002a,b;Ockene et al., 1992; Rosal et al., 1998). A major cause for the study exclusion was

inclusion of participants with other diagnoses than CHD, which included peripheral vascular disease, cardiopulmonary disease, chronic obstructive pulmonary disease,arrhythmias, and hypertension. Based on the abstracts, we did not identify any of thearticles not written in English as potentially eligible studies.

Main characteristics of the included studies are summarized in Table 2 anddescriptions of psychoeducational interventions used in these studies are presented inTable 3. Studies included 1,792 participants in the intervention condition and 1,766

participants in the control condition, ranging from 87 to 789 participants recruited perstudy. All the interventions were initiated in the hospital, and all apart from Hajek,Taylor, and Mills (2002) included some form of home follow-up after hospital discharge.Only one study did not include women among participants, although women were inminority in each study. Studies differed in how far they required motivation to stopsmoking as well in the availability of nicotine replacement products. A range of

approaches were also taken to defining smoking status, so that some studies recruitedonly current smokers (smoking just before the hospital admission), whereas others alsorecruited recent quitters.

Quality of included studies

The results of quality assessment are summarized in Table 4. The randomization methodwas clearly appropriate in 8 of the 14 included studies. Two studies were cluster-randomized trials (Bolman et al., 2002a,b; Johnson, 1999). One trial allocated patientsaccording to the day of admission (Burt et al., 1974); and the method of patientallocation was unclear in three studies (Mohiuddin et al., 2007; Ockene et al., 1992;Rigotti et al., 1994). Only six studies had adequate concealment of allocation. Trial

participants were generally comparable at the baseline. The descriptions ofinterventions and inclusion criteria were appropriate in all included studies.Participants, intervention provider and outcome assessors were not blinded, except



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Table

2.

Maincharacteristicsoftheincludedtria

ls

Study

Setting,country

Interventiontheoryand

intensity

Samplesize

(intervention/control)

Diagnosis,smokingstatusbefore

admission

Age,male(%)

Bolman

etal.

(2002a,b

)

Hospitalandout-patient

clinic,T

heNetherlands

Sociallearningtheory,

attitudesocialinfluence

efficacy(ASE)model;less

intensive

388/4

01

MI,anginapectoris,other.

Smokinginthe7daysbefore

admission

Mean57(11),

male(78%)

Burtetal.(1974)


clinicandcommunity,

UK

Notspecified;intensive

125/98

MI.SmokingatthetimeofMI

attack

Notspecified,

male(100%)

Dornelasetal.

(2000)

Hospitalandcommunity,

USA

Transtheoreticalmodel,

MartlattGordonsrelapse

preventiontechniques;

lessintensive

54/46

AcuteMI.Smokingduringthe

monthbeforeadmission

From27to83,

male(77)

Feeney

etal.

(2001)


clinic,Australia

Notspecified;couldbe

intensive

96/1

02

AcuteMI.Smokingorusing

tobaccoproductsduringthe

weekbeforeadmission

Meanage:53.9

(11),

male(64%)

Hajeketal.(2002)

Hospital,U

K

Notspecified;less

intensive

274/2

66

MI,CABG.Currentorrecent

smokers;notsmokingsince

admission;motivatedtostop

smoking

Under76,mean

age:56(10),

male(77%)

Johnsonetal.

(1999)


Canada

Stagesofchange;less

intensive

50/52

Medicaland/orsurgicalcardia

c

diagnosis.Self-reportedsmok

ers

inthecontemplationstageto

stopsmoking

Over19,meanage:

55(13),male(75%)

Mohiud

dinetal.

(2007)


USA

Stagesofchange(author

inf.);intensive

109/1

00

Acutecoronarysyndrome,

de-compensatedheartfailure.

Dailysmokersforatleast5ye

ars

Aged3075years,

meanage:55(11),

male(63%)



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Table

2.

(Continued)

Study

Setting,country

Interventiontheoryand

intensity

Samplesize

(intervention/control)

Diagnosis,smokingstatusbefore

admission

Age,male(%)

Ockeneetal.

(1992)

andRosal

etal.(1

998)


clinicandcommunity,

USA

Behavioural

multicomponent

approach;couldbe

intensive

135/1

32

Patientswithoneormore

arteriographicalcoronaryartery

lesions.Smokingatleast5

cigarettes/dayanytimeduring

the

last2monthsbeforeadmission

Aged3075years,

meanage:53,

male(75%)

Quist-P

aulsenand

Gallefoss(2003)


Norway

Feararousal;couldbe

intensive

118/1

22

MI,CABG,unstableAngina.D

aily

smokersuntilstartofthepres

ent

coronarysymptoms

Under76,

meanage:57(9),

male(75%)

Reidet

al.(2003)


Canda

Transtheoreticalmodel

(authorinf.);lessintensive

126/1

28

PTCA,M

I,CABG.Fiveormore

cigarettesperdayduringthe

monthbeforeadmission.

Motivationtoquitwasinquired

Over18,meanage:

54(9),male(80%)

Reid,Pipe,

Quinlan,andOda

(2007)


Canada

Notspecified;couldbe

intensive

50/50

CHD.Fiveormorecigarettes

perday

Over18,meanage:

54(9),male(67%)

Rigotti,McKool,

andShiffman

(1994)


USA

Notspecified;less

intensive

44/43

CABG.Smokedoneormore

packsofcigarettesin6months

beforeadmission

Meanage:59(8),

male(77%)

Smitha

ndBurgess

(2009)


Canada

MarlattandGordons

relapsepreventionmodel;

intensive

137/1

39

MI,CABG.Smokinginthemo

nth

beforetheadmission

Over18,meanage:

54(10),male(83%)

Taylor,Houston-

Miller,Killen,and

DeBusk(1990)

Hospital,out-patient

clinicandcommunity,

USA

Sociallearningtheory;

couldbeintensive

86/87

AcuteMI.Smokingduringthe

last

6monthsbeforeadmission

Under70,mean

age:58(9),male

(86%)

Note.M

l,Myocardialinfarction.



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Table

3.

Descriptionofexperimentalandcontro

linterventions

Study

Interventiontheory

Experimentalgroup

Controlgroup

Bolman

etal.

(2002a,b

)

Sociallearningtheory,A

SE

model,theoriesofrelapse

prevention,t

hestageof

changetheory,and

motivationalinterview

strategies

Cardiologistprovidedstopsmokingadvice,w

hichwas

followedby1530standardizedind

ividualcounselling

andprovisionofself-helpmaterialbyanurse.

Counsellingwastailoredtopatientsstageofchangeand

includedassessmentofsmokingbeh

aviour,motivationto

quit,consequencesofquitting,barr

ierstoquitting,and

encouragementtosetadateforqu

itting.Aftercarewas

providedbycardiologistatthefirstout-patient

appointment,whichaddressedvariousaspectsof

smoking.PatientsGPwasinformed

oftheintervention

andaskedtonotesmokingbehavio

ur

Usualcare,nospecialstressonsmoking

cessation

Pharmacotherapynotoffered


Burtetal.(1974)

Notspecified(harmfuleffec

ts

ofsmoking)

Aconsultantexplainedeffectsofsm

okingandadvised

patientstostopsmoking.Participantswereinformedthat

smokingcessationwaslikelytoreduceoccurrenceof

anotherMI.Ifparticipantsfailedtostopsmoking,further

advicewasprovidedandreinforced

byleafletsandadvice

booklet.Afterdischargeparticipantswerefollowedina

clinicandsmokingcessationadvice

wasextendedto

familymembers.Communitynurse

visitedathomeand

gaveadviceregardingsmokingandotherriskfactors

Participantsrece

ivedstandardhospital

advice(unclearaboutdetails),without

follow-upathos

pital.Acommunitynurse

visitedpatientsa

thomeoneormoreyears

latertoseekinformationonsmoking



Dornelasetal.

(2000)

Transtheoreticalmodel,

motivationalintervention,

andMartlattGordons

relapsepreventiontechniques

(copingskillstraining);

dependingonthestageof

change

A20minbedsidesmokingcessationcounsellingby

psychologistwhoevaluatedparticipantscurrentstageof

changeandbasedthecounsellingcontextonthatstage.

Afterdischargeparticipantswerecontactedby

telephoneafterweeks1,4,8,12,16

,20,and29.Bedside

andtelephonecounsellingcombinedaspectsof

motivationalinterviewingandrelap

seprevention

Participantsrece

ivedashortintervention

lastingabout10minfromapsychologist.

Interventioncon

sistedverbalandwritten

recommendationtowatchanon-line

educationalvideowhileinhospital.

Participantswerealsoreferredtolocal

AmericanHeart

orLungAssociations

smokingcessatio

nresources





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Table

3.

(Continued)

Study

Interventiontheory

Experimentalgroup

Controlgroup

Feeney

etal.

(2001)

Notspecified

Relapseprevention:coping

skillstraining(self-efficacy,

Bandurassocialcognitive

theory1986)

StanfordHeartAttackStayingFreep

rogramme.

Participantswereadvisedonsmokin

gcessationand

medicalimplicationsofcessation.Participantsreceiveda

manual,whichidentifiedhigh-riskrelapsesituationsand

exercisestomanagethesesituations.

Audiotapesreviewed

programmesmainpointsandprovidedprogressivemuscle

relaxation.Afterdischargetelephonecontactwasinitiated

weeklyfor4weeksandat2,3,6,and12monthswith

additionalsupportandadvicegivenwhennecessary

Participantsrece

ivedusualcareoffering

verbalandwrittenadviceaboutsmoking

cessation.Includ

edaneducationalvideo

whileinhospital,andreviewbyanalcohol

anddrugassessm

entunit(ADAU)nurse.

Participantswerealsoofferedout-patient

counsellingandfollow-upbyADAUclinic

at3,6,and12m

onthintervals

Pharmacotherapy:informedthatNRTavailable

outsideofhospital.NouseofNRTreported

Pharmacotherapy:informedthat

NRTavailable

outsideofhospital.No

useofNRTreported

Hajeketal.

(2002)

Notspecified(multiple

components,including

informationabouthealth

benefitsofquitting;buddy

support;andself-efficacy)

Participantsweregivenabookletaboutsmokingand

cardiacrecoveryandcarbonmonoxidereadingwas

recorded.T

hebookletchallengedbeliefsthatsmoking

reducesstressandadvisedonrelapseprevention.A

quiz-testedparticipantsknowledge

ofthebooklet,

whichwasalsodiscussedwithanu

rse.Participants

signedadeclarationandastickero

ntheirnotes

remindedstaffofsmokingcessationattempt

Participantsweregivenbothverbaladvice

tostopsmoking

andBritishHeart

Foundationbookletsmokingandyourheart

Pharmacotherapynotoffered.

Veryfew

appearedtohaveusedNRT

Pharmacotherapynotoffered.Very

fewappeared

tohaveusedNRT

Johnsonetal.

(1999)

Stagesofchange;problem

solving,reinforcingthe

patientsself-efficacy

Participantsreceivedabookletandwereshownavideo

abouteffectsofsmoking,importance

ofsmokingcessation,

cessationprocess,andsmokingtrigg

ers.Thevideo

encourageddiscussionofsmokinghabitsandtosetaquit

date.Onthesecondvisit,smokingcessationskillswere

reviewedinavideoandparticipants

developedasmoking

cessationplanandstrategiestomanagesmokingtriggers.

Sixtelephonecontactsduringthefir

st3monthsafter

dischargeencouragedandreinforcedcessationefforts

Participantsinthecontrolgroupreceived

routinecare,wh

ichincludedstopsmoking

advice,butnotasystematicintervention





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Table

3.

(Continued)

Study

Interventiontheory

Experimentalgroup

Controlgroup

Mohiud

dinetal.

(2007)

Multiplecomponents:

relaxationtraining,

contingencycontracting,

socialsupport,copingskills,

stimuluscontrol,andnicotine

fading

Priortodischargeallparticipantsreceivedastandardized

counselling(30min)andself-helpm

aterialonsmoking

cessation

Priortodischargeallparticipantsreceived

astandardizedcounselling(30min)and

self-helpmateria

lonsmokingcessation

Participantsintheinterventiongroupwereaskedto

meetatobaccocessation(60min)weeklyfor3months

insmallgroupsorindividually.Counsellingincluded

relaxationtraining,contingencycontracting,social

support,copingskills,stimuluscontrol,nicotinefading,

andriskfactormodificationsuchasdietandexercise

Noadditionalinterventionprovidedinthe

controlgroup

Pharmacotherapyoffered,usedby75%

Pharmacotherapynotformally

offered;17%reporteduseofNRTor

bupropion

Ockeneetal.

(1992)

and

Rosale

tal.

(1998)

Behaviouralmulticomponen

t

approach:including

motivationalsupport,

behaviouralself-managemen

t

strategies,relaxation,and

scopingskillstraining

Allreceivedstandardizedinitial(10

15min)adviceto

stopsmoking,includingareviewofhealthrisksof

smokingandthebenefitsofquitting,andalistof

communitytreatmentprogrammes

Allreceivedstan

dardizedinitial(1015

min)advicetostopsmoking,includinga

reviewofhealth

risksofsmokingandthe

benefitsofquitting,andalistofcommunity

treatmentprogrammes

Participantsintheinterventiongroupreceiveda30-min

in-patientcounsellingsession,anindividualout-patient

counsellingvisit,andfollow-upcounsellingtelephone

calls.Participantsalsoreceivedinte

rventionmanual,

relaxationtapes,maintenancetraining,andself-help

material

Noadditionalinterventionprovidedinthe

controlgroup



Quist-P

aulsen

(2003)

Feararousal;relapse

preventioncopingskills

Participantswereofferedgroupsessionswithanurse,

withavideoshownandabookletab

outCHDandadvice

aboutquitsmoking

Participantswereofferedgroupsessions

withanurse,withavideoshownanda

bookletaboutC

HDandadviceaboutquit

smoking

Participantsintheinterventiongrou

preceivedaspecially

producedbookletabouthealthben

efitsofquitting

smoking,informationaboutsmokin

gcessation,relapse

prevention,nicotinereplacementproducts,highrisk

Noadditionalinterventionprovided



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Table

3.

(Continued)

Study

Interventiontheory

Experimentalgroup

Controlgroup

relapsesituations,andactionplans.Participantswere

toldinafeararousalmessagethatiftheycontinued

smokingtheywerelikelytohaveanotherheartattack.

Spouseswhosmokedwerealsoaskedtoquit.Telephone

contactwasinitiatedafterdischarge

andparticipantshad

consultationinout-patientclinic

Pharmacotherapy:useofNRT

recommendedfor

thosewithstrongwithdrawalu

rges,usedby36%

Pharmacotherapynotexplicitly

offered,but28%reportedusingNRT

Reidet

al.(2003)

Positivereinforcement,

problemsolving,andsocial

support

Allreceivedbriefbedside,510minindividual

counsellingbyanursecounsellor;andaself-helpbooklet

andinformationonadditionalsuppo

rtfromprimarycare

physiciansprovided

Allreceivedbrie

fbedside,510min

individualcounsellingbyanursecounsellor;

andaself-helpbookletandinformationon

additionalsuppo

rtfromprimarycare

physiciansprovided

Afterhospitaldischarge,participant

sinthestepped-care

groupreceivedthree20-minface-to-facecounselling

sessionswithanurse-counsellorover8weeks.I

f

participantsreportedabstinenceth

eyreceivedpositive

feedbackandwereremindedabouttherelapse

preventioninformationinthebook

let.Ifparticipants

reportedsmoking,counsellingwas

startedandNRT

madeavailable

Noadditionalinterventionprovided

Pharmacotherapy:NRTprovid

edfor4weeks

afterrelapse(26.2%relapsedafterinitialsmoking

cessation)

Pharmacotherapynotoffered.Six

reportedusingNRTandfour

bupropion

Reidet

al.(2007)

Notspecified(self-efficacy,

socialsupport,problem

solving,anddevelopmentof

copingstrategies)

Allreceivedstandardusualcare,includedpersonalized

advicetostopsmokingandNRTif

necessary,brief

bedsidecounsellingbyanurse-counsellor,self-help

guide,andinformationaboutout-pa

tientandcommunity

smokingcessationprogrammes

Allreceivedstan

dardusualcare,included

personalizedadv

icetostopsmokingand

NRTifnecessary,briefbedsidecounselling

byanurse-counsellor,self-helpguide,and

informationaboutout-patientand

communitysmokingcessationprogrammes



13/30


Table

3.

(Continued)

Study

Interventiontheory

Experimentalgroup

Controlgroup

Participantsinthetreatmentgroup

receivedinteractive

voiceresponsivetelephony(IVR)in

tervention.A

fter

dischargeanautomatedtelephonysystemcontacted

participantsondays3,14,and30p

ost-discharge.Calls

inquiredsmokingstatusandassessedriskofrelapse.

Thoseparticipantsthatreportedeitherrelapsewith

willingnesstofurthersmokingcessationattemptorlow

confidencetostaysmokefree,wereflaggedintheIVR

systemsoftware.Nurse-specialistc

ontactedthese

participantstoofferadditionalassistance.A

dditional

interventionsincludeduptothree

20-mincounselling

sessionsover8week-periodcouns

ellor-ledtelephone

sessions,encouragement,helpinid

entifyingsituations

thatwereunderminingtheirconfidenceandpossible

solutions,andaccesstopharmacot

herapy

Noadditionaltreatmentsprovided

Pharmacotherapy:NRTofferedinhospitaland

afterrelapse.Usedby70%inh

ospitalandby14%

afterdischarge

Pharmacotherapy:accesstoNRT

duringhospita

lizationifrequired.

NRTwasused

by58%inhospitaland

by14.3%durin

gfollow-up

Rigotti

etal.

(1994)

Behaviouralandcognitive

methods

BasedontheAmericanLungAssociationsInControl

programme,theinterventionwasa

standardized

counsellingprogramme,whichincludededited

videotape,patientmanual,andthre

e20-minsessionsto

individualpatientsbyaresearchnurse.Familymembers

werealsoencouragedtoparticipate.Within2weeksof

dischargeparticipantswerecontactedbytelephoneto

offersupportandshortcounselling

Participantsrece

ivedstandardpost-

operativecare;includingbriefadvicenotto

smokeaspartofagrouplecture



Smitha

nd

Burgess(2009)

MarlattandGordonsrelapse

preventionmodel

Nursereviewedtwopamphletswiththepatients,w

hich

containedinformationabouthowt

oquitandwhereto

findhelp.Nurseplacedanotetop

atientschartsto

remindtheirphysicianstodeliverscriptednon-smoking

messageatbedside

Nursereviewed

twopamphletswiththe

patients,w

hichcontainedinformation

abouthowtoquitandwheretofindhelp.

Nurseplacedanotetopatientschartsto

remindtheirphysicianstodeliverscripted

non-smokingme

ssageatbedside



14/30


Table

3.

(Continued)

Study

Interventiontheory

Experimentalgroup

Controlgroup

Intheinterventiongroupparticipantsreceivedbedside

counselling(4560min)andeducationalmaterialsto

takehome(video,workbook,audiotape),andseven

telephonecounsellingsessions(at2

,7,1

4,21,3

0,45,6

0

daysafterdischarge).E

ducationconsistedpersonalised

riskassociatedwithsmoking,benefitsofquitting,and

helptodevelopstrategiestostaysm

okefree.Telephone

counsellingfocusedonrelapseprev

entionbydeveloping

cognitive,behavioural,andsocialsu

pportstrategiesfor

situationsidentifiedashighrisksitu

ations

Pharmacotherapynotpartof

intervention,butavailableif

requested,use

dby34%

Pharmacotherapynotpartofintervention,but

availableifrequested,usedby

34%

Tayloretal.

(1990)

Sociallearningtheory,relapse

preventioncopingskills

training

Anursecounsellorreviewedbenefitsofsmoking

cessation,providedamanualandaudiotapesfor

identifyinghighriskrelapsesituations,andprovided

exercisestocopewiththesesituations.A

fterdischarge

telephonecontactwasinitiatedtomonitorrelapseand

offersupportandadvicefor4mon

ths.Out-patient

appointmentwasofferedwhennee

ded.NRTwas

availableandpatientssignedacontracttoquitsmoking

Participantsrece

ivednospecificsmoking

cessationhelp,b

utwerefreetoattend

hospitalsstopsmokingclasses

Pharmacotherapy:NRTavailab

leforstrong

withdrawalurges




15/30


Table4.

Assessmentofstudyqualityofincluded

trials

Study

Random

allocation

method

Allocation

concealed

?Trialarms

similarat

baseline?

Interventions

clearly

described?

Inclusion

eligibility

criteriaset?

O

utcome

assessor

blind?

Intervention

provider

blind?

Participants

blind?

Cessation

verified?

Total

drop-out

rate(%)

Follow-up

(months)

Bolman

etal.

(2002a,b

)

Randomselectionand

assignmentof

hospitals,seven

randomlyassigned,

fourself-selected

condition

No

Somediff.Yes

Yes

No

No

No

No

28

12

Burt(19

74)

Bythedayof

admission

No

Unclear

Yes

Yes

No

No

No

No

0

.12

Dornela

s(2000)

Drawnfrom

envelopes

No

Yes

Yes

Yes

No

No

No

No

20

12

Feeney(2001)

Sealedenvelopes

Yes

Yes

Yes

Yes

No

No

No

Bioch.

66

12

Hajek(2

002)

Seriallynumbered,

opaque,sealed

envelopes

Yes

Yes

Yes

Yes

No

No

No

Bioch.

11

12

Johnson

(1999)

Byadmissionunit

(clusterRCT)

No

Somediff.Yes

Yes

No

No

No

No

14

6

Mohiuddin(2007)

UCwithoutblock

assignment

No

Somediff.Yes

Yes

No

No

No

Bioch.

4

24

Ockene

(1992)

andRos

al(1998)

UC

No

Yes

Yes

Yes

No

No

No

Bioch.

40

60

Quist-Paulen

(2003)

Seriallynumbered,

sealedenvelopes

Yes

Somediff.Yes

Yes

No

No

No

Bioch.

9

12

Reid(20

03)

Usingarandom

numberstable,

stratifiedbyreason

foradmission

UC

Yes

Yes

Yes

No

No

No

Bioch.a

sampleo

nly

(N25)

15

12

Reid(20

07)

Thirdparty,computer

generatedlist

Yes

Yes

Yes

Yes

No

No

No

No

16

12

Rigotti(1994)

UC

No

Yes

Yes

Yes

No

No

No

Bioch.

24

66



16/30


Table4

.(Continued)

Study

Random

allocation

method

Allocation

concealed

?Trialarms

similarat

baseline?

Interventions

clearly

described?

Inclusion

eligibility

criteriaset?

O

utcome

as

sessor

blind?

Intervention

provider

blind?

Participants

blind?

Cessation

verified?

Total

drop-out

rate(%)

Follow-up

(months)

Smith(2

009)

Envelopescontaining

computer-generated

random-number,

randompermuted

blocksof10,stratified

byacuteMIand

CABG

Yes

Yes

Yes

Yes

Ye

s

No

No

Proxy

11

12

Taylor(1990)

Serialnumbered,

sealedenvelopes,

openedbyatrial

coordinator

Yes

Yes

Yes

Yes

No

No

No

Bioch.

25

12

Note.U

C,Unclear.



17/30


the trial by Smith and Burgess (2009) in which outcome assessor was blinded. Smokingcessation was verified in nine studies biologically or by proxy confirmation. Reported

drop-outs during the follow-up (including deaths) ranged from 0 to 66%.

Point prevalent smoking cessation

Thirteen included studies provided sufficient data on point prevalent smoking cessation

(Figure 1). Heterogeneity between studies was statistically significant (p , :0001;

I2

73%). The combined effect size indicated that in comparison to controlinterventions, psychoeducational interventions were associated with a higher rate ofpoint prevalent smoking cessation (RR 1.44, 95% CI, 1.201.73). For this outcome, weconducted one sensitivity analysis by excluding four studies: Bolman et al. (2002a), Burtet al. (1974), Johnson et al. (1999), and Mohiuddin et al. (2007). The heterogeneitybetween studies remained statistically significant (I2 60%), as did the pooled relativerisk (RR 1.28, 95% CI, 1.071.52).

Continuous smoking cessation

Again, there is statistically significant heterogeneity across studies (Figure 2). Thepooled relative risk for the 10 studies that reported this outcome indicated thatpsychoeducational interventions were more effective in increasing continuous smoking

cessation than interventions in the control group (RR 1.51, 95% CI, 1.181.93). For thisoutcome, we performed two sensitivity analyses: first excluding Bolman et al. (2002a)and Mohiuddin et al. (2007), and then excluding Feeney et al. (2001). The results ofthese sensitivity analyses were similar to the result of the main analysis using all included

studies.

Total mortality

Heterogeneity across 10 studies that reported total mortality was not statistically

significant (Figure 3). Pooled relative risk indicated a tendency for a lower total mortality

Study or subgroup

Bolman 2002

Burt 1974

Dornelas 2000

Hajek 2002

Johnson 1999

Mohiuddin 2007

Quist-Paulsen 2003

Reid 2003

Reid 2007

Rigotti 1994

Rosal 1998

Smith 2009

Taylor 1990

Total (95% CI)

Total events

Heterogeneity: Tau2 = 0.07; Chi2 = 44.92, df = 12 (P< 0.0001); I2 = 73%

Test for overall effect: Z = 3.97 (P< 0.0001)

164

79

28

99

23

43

57

49

23

25

47

73

51

761

388

125

54

274

50

109

118

126

50

44

135

137

86

1696

124

27

16

108

16

9

44

46

17

23

37

48

26

541

401

98

46

266

52

100

122

128

50

43

132

139

87

1664

Events Total Events Total Weight

10.1%

8.0%

6.4%

9.8%

6.0%

4.5%

8.6%

8.4%

6.2%

7.6%

7.8%

8.9%

7.7%

100.0%

1.37 (1.13, 1.65)

2.29 (1.62, 3.25)

1.49 (0.93, 2.39)

0.89 (0.72, 1.10)

1.50 (0.90, 2.48)

4.38 (2.25, 8.53)

1.34 (0.99, 1.81)

1.08 (0.79, 1.49)

1.35 (0.83, 2.21)

1.06 (0.73, 1.55)

1.24 (0.87, 1.78)

1.54 (1.17, 2.04)

1.98 (1.38, 2.86)

1.44 (1.20, 1.73)

Treatment Control Risk ratioM-H, random, 95% CI

Risk ratioM-H, random, 95% CI

0.2 0.5 1 2 5

Favours control Favours treatment

Figure 1. Point prevalent smoking cessation outcome comparing effectiveness of psychoeducational

smoking cessation intervention to control condition.



18/30


in the psychological intervention group, although the difference was not statisticallysignificant (RR 0.73, 95% CI, 0.461.15). After excluding the studies by Bolman et al.

(2002a) and Mohiuddin et al. (2007), there were no substantial changes in result (RR0.58, 95% CI, 0.281.18).

Peters method was used to statistically test funnel plot asymmetry (funnel plots notshown). Tests for the point prevalent (p

:

38), continuous (p :

51) smoking cessationand total mortality (p :76) suggested that the funnel plots were not statisticallysignificantly asymmetric, indicating that studies with smaller sample size are notsignificantly associated with greater treatment effects. The results of funnel plot testingshould be interpreted with caution because of the small number of studies included.

Subgroup analyses

The results of the subgroup analyses are summarized in Figure 4. Studies that providedpharmacotherapy for smoking withdrawal symptoms, either nicotine replacement

Study or Subgroup

Bolman 2002

Dornelas 2000

Feeney 2001

Hajek 2002

Mohiuddin 2007

Quist-Paulsen 2003

Rigotti 1994

Rosal 1998

Smith 2009

Taylor 1990

Total (95% CI)

Total events

Heterogeneity: Tau2 = 0.11; Chi2 = 41.07, df = 9 (P< 0.00001); I2 = 78%

Test for overall effect: Z = 3.24 (P= 0.001)

Events

146

23

31

94

36

54

19

40

77

55

575

Total

388

54

96

274

109

118

44

135

137

86

1441

Events

98

12

1

102

9

40

19

31

54

29

395

Total

401

46

102

266

100

122

43

132

139

87

1438

Weight

13.4%

8.3%

1.4%

13.2%

7.1%

11.9%

9.6%

10.7%

12.8%

11.7%

100.0%

1.54 (1.24, 1.91)

1.63 (0.92, 2.91)

32.94 (4.59, 236.59)

0.89 (0.72, 1.12)

3.67 (1.86, 7.23)

1.40 (1.01, 1.92)

0.98 (0.61, 1.57)

1.26 (0.84, 1.89)

1.45 (1.12, 1.87)

1.92 (1.37, 2.69)

1.51 (1.18, 1.93)

Treatment Control Risk ratio

M-H, random, 95% CI

Risk ratio

M-H, random, 95% CI

0.1 0.2 0.5 1 2 5 10Favours control Favours treatment

Figure 2. Continuous smoking cessation outcome comparing effectiveness of psychoeducational

intervention to control condition.

Study or Subgroup

Bolman 2002

Feeney 2001

Mohiuddin 2007

Ockene 1992

Quist-Paulsen 2003

Reid 2003

Reid 2007

Rigotti 1994

Smith 2009

Taylor 1990

Total (95% CI)

Total events

Heterogeneity: Tau2 = 0.07; Chi2 = 10.23, df = 9 (P= 0.33); I2 = 12%

Test for overall effect: Z = 1.36 (P= 0.18)

Events

14

4

3

2

3

1

0

8

2

2

39

Total

388

96

109

135

118

126

50

44

137

86

1289

Events

11

5

12

9

2

1

1

8

2

5

56

Total

401

102

100

132

122

128

50

43

139

87

1304

Weight

24.7%

11.1%

11.9%

8.3%

6.2%

2.7%

2.0%

20.4%

5.2%

7.4%

100.0%

1.32 (0.60, 2.86)

0.85 (0.24, 3.07)

0.23 (0.07, 0.79)

0.22 (0.05, 0.99)

1.55 (0.26, 9.12)

1.02 (0.06, 16.06)

0.33 (0.01, 7.99)

0.98 (0.40, 2.37)

1.01 (0.14, 7.10)

0.40 (0.08, 2.03)

0.73 (0.46, 1.15)

Treatment Control Risk ratio

M-H, random, 95% CI

Risk ratio

M-H, random, 95% CI

0.01 0.1 1 10 100Favours treatment Favours control

Figure 3. Total mortality outcome comparing effectiveness of psychoeducational intervention to

control condition.



19/30


therapy (NRT) or bupropion, to the intervention group only or for all participantstended to report greater treatment effects than those studies that did not offer

pharmacotherapy (Figure 4). However, the differences between these subgroups werestatistically non-significant. A test for subgroup differences indicated that there was nostatistically significant difference in smoking cessation results between studies that

reported or did not report using theory in intervention planning (Figure 4).We judged interventions to be intensive in three studies, could-be-intensive in five

studies, and less intensive interventions in six studies. Analysis for subgroupdifferences suggested that compared to less intensive interventions intensiveinterventions were statistically significantly associated with increased smokingabstinence (Figure 4). We did not find statistically significant differences between the

intensive and the could-be-intensive interventions or between the could-be-intensive and less intensive interventions, although there was a tendency for themore intensive interventions to be associated with larger treatment effects.

Follow-up data for smoking cessation suggested that in comparison to controlinterventions, psychoeducational interventions were effective at 6 months and12 months. Non-significant results at 2460 months for point prevalent cessation, andat 6 months and 2460 months for continuous cessation may be explained by thesmall number of studies that provided relevant data for the analyses (Figure 4).

Investigation of process variables

Studies appeared to report predictor variables rather than process variables and we

encountered difficulties in distinguishing when process variables as opposed topredictor variables had been investigated. Five of the studies appeared to be identifyingprocess variables, but we questioned whether some of these were more appropriately

0 1 2 3 4 0 2 4 6

Pharmac. offered to all

To treat group only

Not offered

Theory group

No theory group

Intensive treatment

Could be intensive

Less intensive

Follow-up 6 mon

Follow-up 12 mon

Follow-up 24-60 mon

Point prevalent Continuous

1 3 5

Figure 4. Results of subgroup or sensitivity analyses relative risk (95% CI) of psychoeducational

intervention to control condition.



20/30


identified as predictor variables. However, we identified the following variables aspotential process variables: stage of change, i.e., readiness to quit smoking, though there

was no interaction with intervention group (Ockene et al., 1992); self-efficacy(Dornelas, Sampson, Gray, Waters, & Thompson, 2000; Reid et al., 2003); signingcommitment to stop smoking; and adherence of intervention participants to procedures(Hajeket al., 2002). We also identified some contradictions. For instance, Johnson et al.(1999) did not find any difference in self-efficacy between the intervention and controlgroup even though the intervention was designed to improve self-efficacy.

Behavioural determinants and behaviour change techniques

All interventions appeared to target multiple behavioural determinants and while weestimated that majority of interventions aimed influence smoking behaviour through

beliefs about capabilities, knowledge, and skills, in our estimation all interventionstargeted participants motivation and goals (Tables 5 and 6). Fewer interventions aimedto modify smoking behaviour through social influences, beliefs about consequences of

continuing smoking, action planning, or emotions. We did not assess any of theinterventions influencing smoking behaviour explicitly through social or professionalrole and identity, memory attention and decision processes, or environmental contextand recourses. While it seemed to us very likely that all interventions targeted attentionand decision processes at some level, this proved to be hard to evaluate and was not

considered in the analysis. In addition, we found it difficult to decide between actionplanning and skills, and decided to record action planning only when this was explicitlymentioned in an intervention. However, it cannot be assumed that elements of actionplanning were not present in interventions where this was not made explicit (Table 5).

We estimate that 14 different behaviour change techniques were used in theinterventions. The most commonly used were: standard, monitoring, behaviouralinformation, relapse prevention, and planning. Less commonly used were: socialsupport, personalized message, feedback, and relaxation. The least-used behaviourchange techniques were: contract, fear arousal, verbal persuasion, coping strategies,motivational interviewing, and buddy systems (Table 5).

Evaluation of techniques suitability

While only a limited number of behaviour change techniques were used, everyintervention used at least one technique recognized by Michie et al. (2008) as

influencing targeted behavioural determinants. We noted, though, that some behaviourchange techniques used in interventions were not recognized as effective in influencingbehavioural determinants by Michie et al. (2008). For example, several trials

investigated relapse prevention, considered ineffective by Michie et al. (2008). Studies,however, tended not only to mention relapse prevention, but also to specify its differentelements (Tables 5 and 6).

Effect of explicit use of theory in intervention planning

Our findings suggested that interventions have deployed diverse theories inintervention planning (Tables 2 and 6). We judged the behavioural determinants

targeted in the interventions to be compatible with assumptions of the differenttheories. Studies that did not include a theoretical model in intervention planningappeared to use similar behavioural determinants to those studies that included theory



21/30


Table

5.

Targetedbehaviouraldeterminantsand

techniquesusedtoinfluencebehaviouraldeterminants

Techniq

uesused

Behaviouraldeterminantsnum

berofstudiesused(andusefulness)

Motivarionand

goals

Beliefsabout

capabilities

Beliefsabout

consequences

Knowledge

Skills

Social

influences

Emotion

Action

planning

Standard

14(Ok)

12(No)

5(Dis)

11(Un)

12(Ok)

7(No)

1(No)

2(Ok)

Relapse

prevention

8(Un)

7(Un)

3(No)

7(No)

7(No)

4(No)

1(No)

2(Un)

Monito

ring

13(Un)

11(Un)

5(Un)

10(No)

11(Ok)

6(Un)

1(No)

2(Un)

Contra

ct

2(Ok)

2(No)

1(No)

2(Ok)

2(No)

2(Dis)

1(Ok)

Planning

11(No)

10(No)

4(No)

9(No)

11(Un)

6(No)

1(Un)

2(Ok)

Feararousal

2(Ok)

2(Ok)

2(Ok)

2(No)

1(No)

1(Dis)

Behavio

uralinformation

11(Ok)

9(Un)

5(Ok)

11(Ok)

10(No)

5(No)

1(No)

2(Dis)

Verbalpersuasion

1(Ok)

1(Ok)

1(Un)

1(Un)

Coping

strategies

1(No)

1(Ok)

1(No)

1(Dis)

Motivationalinterview

2(Ok)

2(Ok)

1(Dis)

1(No)

1(No)

Relaxation

3(No)

3(No)

1(No)

3(No)

3(No)

1(No)

1(No)

Socials

upport

8(Ok)

7(Ok)

3(No)

6(No)

7(No)

6(Ok)

1(Un)

Personalizedmessage

8(Un)

7(Un)

3(Un)

7(Dis)

7(No)

4(No)

1(Un)

Feedback

3(Un)

2(Ok)

2(Ok)

3(No)

3(Dis)

1(No)

1(No)

1(Un)

Note.U

sefulnessoftechniqueswasbasedonMic

hieetal.(2008);Ok,agreeduse;Un,uncertain;Dis,disagreement;No,agreednon-use.



22/30


Table6

.Targetedbehaviouraldeterminantsandusedbehaviourchangetechniquesbythestudiesandbehaviuorchangetechniquessuitabilitytoinfluencebehaviouraldeterminants

Behavioural

determinants

targeted,

Either

givenor

estimated

from

available

information,

Michieetal.

(2008)

Studiesthat

targetgiven

behavioural

determinant

(onlyfirst

author

listed)

Techniqueusedintheintervention

anditsappropriatenesstoinfluenceontargetedbehaviouraldeterminant,Eithergivenintheinterventiondescriptionorestimatedfromavailable

information.TechniquesandtheirappropriatenessaccordingtoMichieetal.(2008)

Standard

Relapse

prevention

Monito

ring

Contract

Planning

Fear

arousal

Behavioural

information

Verbal

persuasion

Coping

strategies

Motivational

interview

RelaxationS

ocial

s

upport

Personalized

message

Feedback

Motivatio

n

andgoals

Bolman

Ok

Un

Dis

Ok

Ok

Un

Burt

Ok

Un

Ok

Ok

Ok

Ok

Dornelas

Ok

Un

Un

Ok

Feeney

Ok

Un

Un

Dis

Ok

No

Hajek

Ok

Un

Ok

Dis

Ok

Un

Johnson

Ok

Un

Dis

Ok

Ok

Un

Un

Mohiuddin

Ok

Un

Dis

Ok

No

No

Ok

Un

Ockeneand

Rosal

Ok

Un

Un

Ok

Un

Quist-

Paulsen

Ok

Un

Un

Dis

Ok

Ok

Un

Reid03

Ok

Un

Un

Dis

Ok

Ok

Un

Reid07

Ok

Un

Dis

Ok

Un

Rigotti

Ok

Un

Dis

Ok

Smith

Ok

Un

Un

Dis

Ok

Ok

Un

Taylor

Ok

Un

Un

Ok

Dis

Ok

No

Ok

Un

Beliefsab

out

capabilities

Bolman

No

Un

No

Un

Ok

Un

Dornelas

No

Un

Un

Ok

Feeney

No

Un

Un

No

Un

No

Hajek

No

Un

No

No

Un

Ok

Johnson

No

Un

No

Un

Ok

Un

Ok

Mohiuddin

No

Un

No

Un

Ok

No

Ok

Un

Ockeneand

Rosal

No

Un

Un

Un

Un

Reid03

No

Un

Un

No

Un

Ok

Un

Reid07

No

Un

No

Ok

Un

Rigotti

No

Un

No

Ok

Smith

No

Un

Un

No

Un

Ok

Un

Taylor

No

Un

Un

No

No

Un

No

Ok

Un



23/30


Table6

.(Continued)

Behavioural

determinants

targeted,

Either

givenor

estimated

from

available

information,

Michieetal.

(2008)

Studiesthat

targetgiven

behavioural

determinant

(onlyfirst

author

listed)




Standard

Relapse

prevention

Monito

ring

Contract

Planning

Fear

arousal

Behavioural

information

Verbal

persuasion

Coping

strategies

Motivational

interview

RelaxationS

ocial

s

upport

Personalized

message

Feedback

Beliefsab

out

conseque

nces

Bolman

Dis

Un

No

Ok

Dis

Un

Burt

Dis

Un

Ok

Ok

Ok

No

Quist-

Paulsen

Dis

No

Un

No

Ok

Ok

Ok

Smith

Dis

No

Un

No

Ok

No

Un

Taylor

Dis

No

Un

No

No

Ok

No

No

Un

Ok

Knowledge

Bolman

Un

No

No

Ok

No

Dis

Burt

Un

No

Ok

Ok

Un

No

Feeney

Un

No

No

No

Ok

No

Hajek

Un

No

Ok

No

Ok

No

Johnson

Un

No

No

Ok

No

Dis

No

Mohiuddin

Un

No

No

Ok

No

No

No

Dis

Ockeneand

Rosal

Un

No

No

Ok

Dis

Quist-

Paulsen

Un

No

No

No

Ok

Ok

No

Reid03

Un

No

No

No

Ok

No

Dis

Smith

Un

No

No

No

Ok

No

Dis

Taylor

Un

No

No

Ok

No

Ok

No

No

Dis

Skills

Bolman

Ok

Ok

Un

No

No

No

Feeney

Ok

No

Ok

Un

No

No

No

Hajek

Ok

No

No

Un

No

Dis

Johnson

Ok

Ok

Un

No

No

No

Dis

Mohiuddin

Ok

Ok

Un

No

Dis

No

No

No

Ockeneand

Rosal

Ok

No

Ok

No

No

Quist-

Paulsen

Ok

No

Ok

Un

No

No

Dis

Reid03

Ok

No

Ok

Un

No

No

No



24/30


Table6

.(Continued)

Behavioural

determinants

targeted,

Either

givenor

estimated

from

available

information,

Michieetal.

(2008)

Studiesthat

targetgiven

behavioural

determinant

(onlyfirst

author

listed)




Standard

Relapse

prevention

Monito

ring

Contract

Planning

Fear

arousal

Behavioural

information

Verbal

persuasion

Coping

strategies

Motivational

interview

RelaxationS

ocial

s

upport

Personalized

message

Feedback

Reid07

Ok

Ok

Un

No

No

Rigotti

Ok

Ok

Un

No

Smith

Ok

No

Ok

Un

No

No

No

Taylor

Ok

No

Ok

No

Un

No

No

No

No

Social

influences

Burt

No

Un

No

Un

Ok

Hajek

No

No

Dis

No

No

No

Reid03

No

No

Un

No

No

Ok

No

Reid07

No

Un

No

Ok

No

Rigotti

No

Un

No

Ok

Smith

No

No

Un

No

No

Ok

No

Taylor

No

No

Un

Dis

No

No

No

Ok

No

Emotion

Quist-

Paulsen

No

No

No

Un

No

No

No

Action

planning

Quist-

Paulsen

Ok

Un

Un

Ok

Dis

Dis

Un

Taylor

Ok

Un

Un

Ok

Ok

Dis

No

Un

Un

Note.O

k,techniqueappropriatetochangebehaviouraltargetaccordingtoMichieetal.(2008);Un,un

certthereisuncertaintyabouttechniqueseffectiveness/appropriatenessto

changebehaviouraldeterminantaccordingtoMichieet

al.(2008);No,techniquenotappropriatetochangebehaviouraldeterminantaccordingtoMichieetal.(2008);Dis,disagree

thereis

disagreementabouttechniquesappropriateto

changebehaviouraldeterminantaccordingtoM

ichieetal.(2008);,interventiondidnotuse

thistechnique;buddysystem

(Hajeketal.)notincludedinthelistasthereisnoinformationavailableinMichieetal.(2008)aboutte

chniquesappropriatenessoreffectiveness.



25/30


in intervention planning. We noted, however, some differences in behaviour changetechniques used. It appeared that those studies that explicitly included theory in

intervention planning, used diverse techniques more frequently and to a greater extentthan studies in the group not deploying theory. Intervention intensity, on the otherhand, did not appear to exert any marked influence on targeted behaviouraldeterminants or behaviour change techniques.

Discussion

Results of our meta-analysis suggested that psychoeducational smoking cessationinterventions for CHD patients are effective. Psychoeducational interventionssignificantly increased rates of smoking cessation, and statistically non-significantlyreduced total mortality. While our results are in line with the findings of previousreviews and meta-analyses (e.g., Rigotti et al., 2007; Van Berkel et al., 1999), our reviewconcentrated on CHD patients and psychoeducational interventions. In addition, wetested an innovative approach to investigating intervention mechanisms.

We found that analysing and interpreting the results posed certain challenges. Apart

from the total mortality rate, analysis showed high levels of unexplained variationbetween the studies, which could not be accounted for by chance. Methodologicalappraisal and sensitivity analysis suggested that methodological diversity between the

studies could not alone account for the variation found. To further explore, the possiblecauses of heterogeneity for point prevalent and continuous smoking cessation, we didunplanned post hoc subgroup analysis. However, the results of the subgroup analysesshould be treated with caution as the number of studies included in some subgroupswere very small.

The effectiveness of pharmacotherapy in smoking cessation is well established

(Stead, Perera, Bullen, Mant, & Lancaster, 2008; Woolacott et al., 2002). We usedpost hocanalyses to investigate the effects of pharmacotherapy, intervention theory andintensity, and length of follow-up to intervention outcomes. Similarly to Rigotti et al.

(2007), we found that adding pharmacotherapy to psychoeducational intervention didnot cause statistically significant improvement in rates of smoking cessation comparedto psychoeducational intervention alone.

As theories of behaviour change can guide intervention planning by making itexplicit how the desired behaviour change can be achieved, we tested whether explicitinclusion of theory in intervention planning influences the effectiveness of theintervention. However, we did not find any statistically significant difference betweengroups that explicitly mentioned theory in intervention planning and those that did notreport using any theory. We do not view this result as suggesting that using a theory in

intervention planning would be wasted effort. On the contrary, this result highlights theimportance of examining actual theories or mechanisms underlying interventions,rather than simply considering whether theories are explicitly stated or not. Thisconsideration also highlights the increased need for practitioners and researchers whoare involved in intervention planning and report writing to report, not only interventionprocedures, but also how they suggest that the intervention causes the desired change.

We found, similarly to Rigotti et al. (2007), that there was a significant difference in

rates of smoking cessation between intensive and less-intensive interventions. Whilerecognizing the methodological problems associated with classifying the interventionsinto the reported subgroups, results suggest that less-intensive interventions may not



26/30


have been able to offer enough support especially for those participants that werestruggling to maintain cessation. While intensive interventions are likely to require more

resources, especially in terms of health care professionals time, they may not beapplicable to every situation. It is also worth noting that we considered only two studiesas intensive, and that regardless of studies intensity and in contrast to controltreatments, most of the studies included some form of supportive contact afterdischarge from hospital. Consistent with our findings, Rigotti et al. (2007) concludedthat high-intensity interventions that begin during hospitalization and provide at least

1 months supportive follow-up after discharge do increase smoking cessation amongparticipants. At the present, the cumulative evidence for hospitalized patients suggeststhat a successful smoking cessation intervention should consist of substantial in-patientintervention followed by supportive contact after discharge from hospital.

Our estimates of smoking abstinence at different time points show that the effects ofpsychological interventions were evident up to 24 months. Results from the differentfollow-up points should nevertheless be interpreted with caution, as the small number oftrials or patients included in the analyses may have led to wide or statistically non-significant confidenceintervals at certaintime points, rather than measuring interventionineffectiveness as such. Collecting reliable long-term follow-up data for this kind ofpsychoeducational intervention is challenging, as it is difficult to evaluate influence ofmany possible confounding factors that may have influenced the results, such as adviceand support received from other sources by the control group participants.

We did not find evidence of systematic testing of process variables, and in many casesit was problematic to decide whether an identified variable should be considered as apredictor or a process variable, as in many cases, such as with self-efficacy, a variable

could have both functions. While we judged that five studies did investigate process variables, there was not enough information available to reliably identify processesunderlying successful smoking cessation.

While our statistical analyses offered only limited information about interventionmechanisms and features, our qualitative assessment of behavioural determinants andbehaviour change techniques using the framework provided by Michie et al. (2008)suggested considerable similarities between the interventions. Those interventionsincluded in this review, tended to emphasize individuals responsibility for theirsmoking and aimed to improve smoking cessation via participants knowledge, skills,

and beliefs about their capabilities to stop smoking and continuing abstinence.Considering the available pool of (137) behaviour change techniques listed by Michieet al. (2008), interventions were found to deploy a rather more limited number oftechniques, all relatively straightforward to apply in practice, to deliver to high numbersof people, and requiring limited staff training. Our analyses do not permit us tocomment on whether the limited pool of behaviour change techniques in use reflectstheir comparative practicability or effectiveness. Analysing behavioural determinantsand behaviour change techniques, however, raises practical considerations. As the poolof techniques deployed in interventions was limited, we must consider whether the

results of the meta-analysis are only generalizable to smoking cessation interventionsthat use similar techniques than interventions in this review. As this is the first attemptto analyse retrospectively behavioural determinants and behaviour change techniquesin interventions, we should be cautious in interpreting the evidence. What our results

do indicate, however, is that relatively straightforward behaviour change techniques thatare also comparatively easy to apply in practice can be effective in changing smokingbehaviour. What separated interventions from each others in this review, was not so



27/30


much the behaviour change techniques used or the behavioural determinants targetedbut how behaviour change techniques were combined and applied in practice.

Michie et al. (2008) argue that not all behaviour change techniques are effective inchanging behavioural determinants. We evaluated the effectiveness of behaviour changetechniques in influencing behavioural determinants in the interventions, based on theexpert opinion of Michie et al. (2008). Interestingly, these findings suggested that somecommonly used intervention techniques such as relapse prevention and personalizedmessages may not be effective. Also, although most interventions used at least one

agreed technique to influence-targeted behavioural determinants, interventionsinvestigated in some trials, for example Feeney et al. (2001), did not appear to usesuch agreed techniques for all targeted behavioural determinants. While these findingsare tentative and open to debate, they nevertheless highlight the need for intervention

planners to make explicit what different intervention components are aiming toachieve.

Although we found our approach to meta-analysis useful and informative, weencountered considerable difficulties when retrospectively evaluating behaviouraldeterminants. It was especially difficult to differentiate between skills and actionplanning, and to identify memory attention and decision processes. Part of theproblem here undoubtedly relates to the limited space available for the reporting of anyintervention and the usual practice of providing a description of the interventionunaccompanied by even brief explanation of the intervention rationale, i.e., why or how

the desired behaviour change should be achieved.Some of the included studies had not been considered in other meta-analyses as

randomized controlled trials (Burt et al., 1974; Johnson et al., 1999), but performed

sensitivity analyses showed that inclusion of these studies did not essentially change theresults. Although we did include unpublished data from the authors, data analyses werealso carried out using conservative methods to guard against overestimation of anytreatment effect. The large between-study variation also raised questions about theappropriateness of meta-analysis, but we felt that the observed heterogeneity was animportant part of the results, indicating the complexity of the interventions included inthe review.

Although the retrospective evaluation of interventions entails some problems, it mayoffer the potential to improve the understanding of interventions included in the review.

However, various problems confronted us while using the study by Michie et al. (2008) within our own process of evaluation, as when we found the descriptions of somebehaviour change techniques to be confusing or inadequate. Michie et al. (2008) hadalso constructed a consensus table of the suitability of behaviour change techniques toinfluence behavioural determinants. For us, however, it appeared that many of the 35behaviour change techniques included in the consensus table were actuallycombinations of originally listed techniques within a new composite description,making any subsequent evaluation process more rather than less complex. Anotherdifficulty with taking this approach was that assessing the suitability of techniques was

based on expert opinion, rather than on empirical evidence.

Conclusions

Psychoeducational smoking cessation interventions are associated with increased ratesof smoking cessation. The results of post hoc subgroup analyses suggested thatintervention intensity was associated with intervention effectiveness. Meta-analysis



28/30


indicated a high level of heterogeneity and interventions appeared to be very differentfrom each other. However, the examination of behavioural determinants and behaviour

change techniques suggested less than expected variation in the interventiontechniques used. Results of the meta-analyses may only be generalizable to smokingcessation interventions that use similar techniques to interventions in this review.

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