Accessing National Health Service Stop Smoking Services in the UK: a COM-B analysis of barriers and facilitators perceived by smokers, ex-smokers and stop smoking advisors

Does socioeconomic position moderate the associations between the content and delivery features of digital behaviour change interventions for smoking cessation and intervention effectiveness? A systematic review and meta-analysis

Prior research indicates that digital smoking cessation interventions can be effective, but little is known about their active ingredients. Therefore, this review aimed to examine the associations of content (behaviour change techniques [BCTs]), delivery features (delivery mode, readability, ease-of-use), and socioeconomic position with effectiveness. Systematic searches and hand searches were conducted from February to June 2023 to identify experimental evaluations of digital smoking cessation interventions published since 2004. Random-effects meta-analyses were used to explore intervention effectiveness. Meta-CART were used to explore whether content, delivery features, or socioeconomic position moderate effectiveness and assessed interactions between potential moderators. Meta-regressions were performed as sensitivity checks. For k = 29 studies (n = 42,662), the authors provided sufficient data and materials for inclusion in the primary analyses. Participants in the intervention groups had greater odds of successfully quitting smoking (OR = 1.29, 95% CI: 1.10-1.51, p = .002) with similar effect sizes across socioeconomic groups (ORlow SEP = 1.25, 95% CI: 1.00-1.57, p = .048; ORhigh SEP = 1.36, 95% CI: 1.06-1.76, p = .017). No delivery features were significantly associated with effectiveness. The BCT 'commitment' was associated with larger effects in populations with high, but not low, socioeconomic positions. There were no significant interactions between potential moderators. Digital smoking cessation interventions are effective across socioeconomic groups. Uncertainty around active ingredients remains.

Effectiveness of the Offer of the Smoke Free Smartphone App Compared With No Intervention for Smoking Cessation: Pragmatic Randomized Controlled Trial

BACKGROUND

Digital technologies offer the potential for low-cost, scalable delivery of interventions to promote smoking cessation.

OBJECTIVE

We aimed to evaluate the effectiveness of the offer of Smoke Free-an evidence-informed, widely used app-for smoking cessation versus no support.

METHODS

In this 2-arm randomized controlled trial, 3143 motivated adult smokers were recruited online between August 2020 and April 2021 and randomized to receive an offer of the Smoke Free app plus follow-up (intervention arm) versus follow-up only (comparator arm). Both groups were shown a brief message at the end of the baseline questionnaire encouraging them to make a quit attempt. The primary outcome was self-reported 6-month continuous abstinence assessed 7 months after randomization. Secondary outcomes included quit attempts in the first month post randomization, 3-month continuous abstinence assessed at 4 months, and 6-month continuous abstinence at 7 months among those who made a quit attempt. The primary analysis was performed on an intention-to-treat (ITT) analysis basis. Sensitivity analyses included (1) restricting the intervention group to those who took up the offer of the app, (2) using complete cases, and (3) using multiple imputation.

RESULTS

The effective follow-up rate for 7 months was 41.9%. The primary analysis showed no evidence of a benefit of the intervention on rates of 6-month continuous abstinence (intervention 6.8% vs comparator 7.0%; relative risk 0.97, 95% CI 0.75-1.26). Analyses of all secondary outcomes also showed no evidence of a benefit. Similar results were observed on complete cases and using multiple imputation. When the intervention group was restricted to those who took up the offer of the app (n=395, 25.3%), participants in the intervention group were 80% more likely to report 6-month continuous abstinence (12.7% vs 7.0%; relative risk 1.80, 95% CI 1.30-2.45). Equivalent subgroup analyses produced similar results on the secondary outcomes. These differences persisted after adjustment for key baseline characteristics.

CONCLUSIONS

Among motivated smokers provided with very brief advice to quit, the offer of the Smoke Free app did not have a detectable benefit for cessation compared with follow-up only. However, the app increased quit rates when smokers randomized to receive the app downloaded it.

TRIAL REGISTRATION

ISRCTN ISRCTN85785540; https://www.isrctn.com/ISRCTN85785540.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-https://onlinelibrary.wiley.com/doi/full/10.1111/add.14652.

The Latrobe Smoking Support Service: A quantitative study of participants in a regional area

Background and Aims

More than 70% of current smokers in Australia have a definite plan to stop smoking and around half of them try to quit every year. Latrobe Community Health Service (LCHS) was commissioned by Gippsland Primary Health Network to establish Latrobe Smoking Support Service (LSSS) to break down barriers to accessing services and increase support for smoking cessation. This research aims to assess the feasibility of an ongoing smoking cessation support service and determine the effect the LSSS has on client smoking behavior.

Methods

Quantitative data were collected for the LSSS situated at LCHS during the period from September 2021 to March 2022. A new client survey, a returning client survey, and a 6-week follow-up survey were conducted by Clinic staff. The consent forms were obtained from the clients. A total of 117 clients attended the LSSS at least once, and a further 315 returning client sessions were conducted. The data analysis was undertaken by means of various descriptive and inferential statistical techniques, such as multiple linear regression analysis.

Results

The research findings demonstrate the strong positive effect of the LSSS in helping clients to change their smoking behavior. Results of multiple regression analysis highlight the significant role of behavioral intervention strategies in the LSSS's success. A combination of both nicotine replacement therapy (NRT) and counseling was a key contributor to the project's success.

Conclusion

This research proposed and tested the model of a smoking cessation support service that combines a comprehensive mix of services for smokers including free NRT, free counseling, and ongoing support of counselors or/and nurse practitioners.

A COM-B analysis of facilitators of and barriers to smoking cessation among Chinese smokers: A qualitative study

INTRODUCTION

Smoking prevalence remains high in China with a low cessation motivation level, despite the government's tobacco control efforts. There is a lack of research specifically examining perceptions, attitudes, and behaviors related to smoking cessation in this region, particularly from a theory-based deductive perspective. Utilizing the COM-B (Capability, Opportunity, Motivation-Behavior) model as a theoretical framework, this study aimed to identify facilitators and barriers to smoking cessation among Chinese smokers.

METHODS

The study employed semi-structured individual interviews with 40 participants. Each interview spanned approximately 30 minutes. The participants, constituting both current and former smokers, were all aged ≥18 years (n=40). Interview data were then examined using a directed content analysis approach.

RESULTS

Analysis revealed three interrelated themes. Capability: Smokers face challenges when resisting peer pressure and dealing with life after quitting. They also lack knowledge about smoking, quitting techniques, and withdrawal symptoms. Opportunity: Changing societal attitudes towards smoking create opportunities for quitting, but these are hindered by inadequate cessation services and a lack of family support. Motivation: Smokers' motivation to quit is mainly driven by health concerns. Resistance to quitting often stems from the belief that smoking is a personal choice or just a habit. Excessive emphasis on willpower may hinder motivation to quit.

CONCLUSIONS

To enhance smoking cessation efforts in China, three key aspects should be considered: capability, opportunity, and motivation. Publicity and educational campaigns should target common misconceptions about smoking as a personal freedom, correct the overemphasis on willpower, and widely promote available cessation services. A crucial aspect is shifting societal norms to foster anti-smoking sentiments. Effective strategies may involve using real-life stories to illustrate smoking's health consequences, disseminating information about cessation services in maternity centers, enhancing services through mobile health initiatives, and empowering families to support smokers in their quit attempts.

Factors influencing dairy farmers' antibiotic use: An application of the COM-B model

In dairy farming, mastitis treatment is the most common reason for antimicrobial use. The overuse or misuse of antibiotics in agriculture has been associated with the development and spread of antimicrobial resistance (AMR). Traditionally, blanket dry cow therapy (BDCT), in which all cows receive antibiotic treatment, was used prophylactically to prevent and manage disease spread. In recent years, there has been a move toward selective dry cow therapy (SDCT), in which only clinically infected cows are treated with antibiotics. This study aimed to explore farmer attitudes toward antibiotic use (ABU), using the COM-B (Capability-Opportunity-Motivation-Behavior) model as a framework, to identify predictors of changing behavior toward SDCT and suggest interventions to encourage its uptake. Participant farmers (n = 240) were surveyed online between March and July 2021. Five items were found to be significant predictors of farmers having stopped BDCT: (1) having lower knowledge of AMR, (2) greater awareness of AMR and ABU (Capability), (3) feeling social pressure to reduce ABU (Opportunity), and (4) having greater professional identity, and (5) having positive emotions associated with stopping BDCT (Motivation). Direct logistic regression found that these 5 factors explained between 22 and 34.1% of the variance in making changes to BDCT practices. Additionally, objective knowledge was not correlated with current positive antibiotic practices, and farmers often perceived their antibiotic practices as more responsible than they actually were. A multifaceted approach, encompassing each of the predictors highlighted, should be taken to encourage farmer behavior change in relation to stopping BDCT. Additionally, as farmers' perceptions of their own behaviors may not align with their actual practices, awareness raising of what constitutes "responsible" behavior should be targeted at dairy farmers to motivate them to take action and adopt more responsible antibiotic practices.

Exploring veterinarians' behaviour relating to antibiotic use stewardship on Irish dairy farms using the COM-B model of behaviour change

Employing a theoretical model of human behaviour (COMB), the current study explores the factors influencing veterinarians' engagement with antibiotic use stewardship on Irish dairy farms. One-to-one semi structured interviews were carried out by telephone with 12 veterinarians whose daily work focused on dairy cattle. A thematic analysis approach was undertaken. The identified themes and sub-themes were then mapped to the COM-B model. This study identified challenges faced by veterinarians when trying to prescribe responsibly which included lack of training to encourage farmer behaviour change, issues with laboratory testing, pressures from farmers to prescribe antimicrobials, concern for animal welfare and farmers going elsewhere for prescriptions. Having a good knowledge of AMR, peers as an advice source, potential financial benefits for farmers as a result of reduced antimicrobial costs and accepting a shared responsibility for AMR, facilitate veterinarians in their role as antimicrobial stewards. The barriers and facilitators identified as influencing veterinarians' capability, opportunity and motivation to responsibly prescribe antimicrobials formed the basis for a number of practical recommendations which should be considered by advisory and policy making teams. Recommendations include; continuous training for veterinarians on AMR and alternatives to overcome the barriers faced when trying to promote reduced AMU, veterinarian peer support groups to improve confidence in their knowledge and decision making to minimise the effect of client pressures/expectations, setting up collaborative farmer and veterinarian working groups to promote a transparent working relationship and the development of affordable and efficient diagnostic and susceptibility testing.

Accessing specialist support to stop smoking in pregnancy: A qualitative study exploring engagement with UK-based stop smoking services

Objectives

Specialist stop smoking services can be effective for supporting women with smoking cessation during pregnancy, but uptake of these services is low. A novel theoretical approach was used for this research, aiming to identify barriers to and facilitators of engaging with specialist smoking cessation support using the Theoretical Domains Framework (TDF).

Methods

Semi‐structured interviews and a focus group (n = 28) were carried out with pregnant women who smoke/recently quit smoking, midwives and Stop Smoking in Pregnancy advisors from two local authority commissioned services in the UK. Inductive thematic analysis was used to code interview transcripts and deductive thematic analysis used to match emerging themes to TDF domains.

Results

Themes corresponded to seven domains of the TDF: Knowledge: Knowledge of available services for pregnant smokers; Environmental context and resources: Uptake of referral to cessation services by pregnant smokers; Social Influences: Smoking norms and role of others on addressing smoking in pregnancy; Beliefs about Capabilities: Confidence in delivering and accepting pregnancy smoking cessation support; Beliefs about Consequences: Beliefs about risks of smoking in pregnancy and role of cessation services; Intentions: Intentions to quit smoking during pregnancy; Emotions: Fear of judgement from healthcare professionals for smoking in pregnancy.

Conclusions

These novel findings help to specify factors associated with pregnant women’s engagement, which are useful for underpinning service specification and design by public health commissioners and service providers. Addressing these factors could help to increase uptake of cessation services and reduce rates of smoking in pregnancy.

A digital behaviour change intervention to increase booking and attendance at Stop Smoking Services: the MyWay feasibility RCT

Background

Smoking remains a leading cause of illness and preventable death. NHS Stop Smoking Services increase quitting, but, as access is in decline, cost-effective interventions are needed that promote these services. StopApp™ (Coventry University, Coventry, UK) is designed to increase booking and attendance at Stop Smoking Services.

Design

A two-arm feasibility randomised controlled trial of StopApp (intervention) compared with standard promotion and referral to Stop Smoking Services (control) was conducted to assess recruitment, attrition and health equity of the design, alongside health economic and qualitative process evaluations.

Setting

Smokers recruited via general practitioners, community settings and social media.

Participants

Smokers aged ≥ 16 years were recruited in one local authority. Participants had to live or work within the local authority area, and there was a recruitment target of 120 participants.

Interventions

StopApp to increase booking and attendance at Stop Smoking Services.

Main outcome measures

Participants completed baseline measures and follow-up at 2 months post randomisation entirely online. Objective data on the use of Stop Smoking Services were collected from participating Stop Smoking Services, and age groups, sex, ethnicity and socioeconomic status in baseline recruits and follow-up completers/non-completers were assessed for equity.

Results

Eligible participants (n = 123) were recruited over 116 days, with good representation of lower socioeconomic status groups; black, Asian and minority ethnic groups; and all age groups. Demographic profiles of follow-up completers and non-completers were broadly similar. The attrition rate was 51.2%, with loss to follow-up lowest in the social media setting (n = 24/61; 39.3%) and highest in the general practitioner setting (n = 21/26; 80.8%). Most measures had < 5% missing data. Social media represented the most effective and cost-efficient recruitment method. In a future, definitive, multisite trial with recruitment driven by social media, our data suggest that recruiting ≥ 1500 smokers over 12 months is feasible. Service data showed that five bookings for the Stop Smoking Services were scheduled using StopApp, of which two did not attend. Challenges with data access were identified. A further five participants in the intervention arm self-reported booking and accessing Stop Smoking Services outside StopApp compared with two control arm participants. Event rate calculations for the intervention were 8% (Stop Smoking Services data), 17% (including self-reports) and 3.5% from control arm self-reports. A conservative effect size of 6% is estimated for a definitive full trial. A sample size of 840 participants would be required to detect an effect for the primary outcome measure of booking a Stop Smoking Services appointment in a full randomised controlled trial. The process evaluation found that participants were satisfied with the research team contact, study methods and provision of e-vouchers. Staff interviews revealed positive and negative experiences of the trial and suggestions for improvements, including encouraging smokers to take part.

Conclusion

This feasibility randomised controlled trial found that, with recruitment driven wholly or mainly by social media, it is possible to recruit and retain sufficient smokers to assess the effectiveness and cost-effectiveness of StopApp. The study methods and measures were found to be acceptable and equitable, but accessing Stop Smoking Services data about booking, attendance and quit dates was a challenge. A full trial may be feasible if service data are accessible. This will require careful planning with data controllers and a targeted social media campaign for recruitment. Changes to some study measures are needed to avoid missing data, including implementation of a more intensive follow-up data collection process.

Future work

We plan a full, definitive randomised controlled trial if the concerns around data access can be resolved, with adaptations to the recruitment and retention strategy.

Limitations

Our trial had high attrition and problems with collecting Stop Smoking Services data, which resulted in a reliance on self-reporting.

Trial registration

Research Registry: 3995. The trial was registered on 18 April 2018.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Designing a comprehensive behaviour change intervention to promote and monitor exclusive use of liquefied petroleum gas stoves for the Household Air Pollution Intervention Network (HAPIN) trial

INTRODUCTION

Increasing use of cleaner fuels, such as liquefied petroleum gas (LPG), and abandonment of solid fuels is key to reducing household air pollution and realising potential health improvements in low-income countries. However, achieving exclusive LPG use in households unaccustomed to this type of fuel, used in combination with a new stove technology, requires substantial behaviour change. We conducted theory-grounded formative research to identify contextual factors influencing cooking fuel choice to guide the development of behavioural strategies for the Household Air Pollution Intervention Network (HAPIN) trial. The HAPIN trial will assess the impact of exclusive LPG use on air pollution exposure and health of pregnant women, older adult women, and infants under 1 year of age in Guatemala, India, Peru, and Rwanda.

METHODS

Using the Capability, Opportunity, Motivation-Behaviour (COM-B) framework and Behaviour Change Wheel (BCW) to guide formative research, we conducted in-depth interviews, focus group discussions, observations, key informant interviews and pilot studies to identify key influencers of cooking behaviours in the four countries. We used these findings to develop behavioural strategies likely to achieve exclusive LPG use in the HAPIN trial.

RESULTS

We identified nine potential influencers of exclusive LPG use, including perceived disadvantages of solid fuels, family preferences, cookware, traditional foods, non-food-related cooking, heating needs, LPG awareness, safety and cost and availability of fuel. Mapping formative findings onto the theoretical frameworks, behavioural strategies for achieving exclusive LPG use in each research site included free fuel deliveries, locally acceptable stoves and equipment, hands-on training and printed materials and videos emphasising relevant messages. In the HAPIN trial, we will monitor and reinforce exclusive LPG use through temperature data loggers, LPG fuel delivery tracking, in-home observations and behavioural reinforcement visits.

CONCLUSION

Our formative research and behavioural strategies can inform the development, implementation, monitoring and evaluation of theory-informed strategies to promote exclusive LPG use in future stove programmes and research studies.

TRIAL REGISTRATION NUMBER

NCT02944682, Pre-results.