dissertation final draft 2108

APPROACHES TO SMOKING CESSATION AND SELF-EFFICACY

Comparing the effectiveness of two different approaches to smoking cessation in increasing smoking

cessation self-efficacy. A randomised controlled trial of two online interventions.

Name: Riyad El-Moslemany

Supervisor: Dr. Molly Byrne

Student number: 13230187

Word count: 4959

This manuscript was formatted according to the British Journal of Health Psychology author

guidelines.

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Acknowledgements

I would like to sincerely thank my supervisor, Dr. Molly Byrne, for her invaluable help. I would also

like to thank all the staff and PhD students within the School of Psychology NUI Galway.

I would like to express my special thanks to Joe Mee, Declan Coogan, and Patrick Mannion for their

help and support with technical issues, which made this project possible.

Thanks also to Teresa Corbett, fellow MSc students, and all the participants for their time and input.

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Abstract

Objectives: To assess whether a gradual approach to smoking cessation is more effective, than an

abrupt approach in increasing smoking cessation self-efficacy. Little is known about individuals’

cognitions around smoking cessation depending on cessation method.

Design: Randomised controlled trial with data collection at two time points (baseline, follow-up

period). Participants were randomised into one of two online interventions. One advocated an

abrupt approach to smoking cessation (STOP), the other advocated a gradual approach (REDUCE).

Methods: 100 participants completed the baseline questionnaire and were randomly assigned to

one of two intervention conditions; full data were available for 29 participants at follow-up post

intervention. Four 2 x 2 mixed ANOVA’s were employed to analyse the participants’ data. Data from

29 participants was included in the final analysis. The ANOVA’s analysed score on the self-efficacy

questionnaire (SEQ-12), cigarettes per day (CPD), and scores on confidence and motivation.

Results: There was a significant decrease from baseline to follow-up in CPD (F (1,26) = 22.84, p = .00, η2 p

= .47) and in motivation to quit (F(1,27) = 13.46, p = .00, η2 p = .33). There were no effects for scores on

the SEQ-12 or confidence over time or between groups. There were no significant differences

between the abrupt and gradual interventions on any outcome measures following the intervention.

Conclusions: Our study suggests that there were no differences between abrupt and gradual

approaches to smoking cessation in terms of increasing smoking cessation self-efficacy. Results

suggest that the two interventions were effective at decreasing smoking behaviour as CPD

decreased. Further research is needed to find more successful ways of getting participants to engage

with online interventions and increase and maintain motivation.

Keywords

smoking cessation, self-efficacy, online interventions, confidence, motivation.

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Introduction

Smoking remains the largest single preventable cause of premature death and illness worldwide

(Shafey et al., 2009; World Health Organisation, 2009). The World Health Organisation (WHO)

estimated that tobacco caused 5.4 million deaths in 2004 and 100 million deaths over the course of

the 20th century. There is a pressing need to find better ways of helping smokers to stop. Quitting

smoking has immediate as well as long-term benefits, reducing risks for diseases caused by smoking

and improving health in general (U.S. Department of Health and Human Services, 2004). Britton &

Edwards (2008) argue that millions of current smokers are unlikely to stop in the near future,

therefore in addition to conventional tobacco control policies, the application of harm reduction

principles to nicotine and tobacco use could deliver substantial reductions in the morbidity and

mortality currently caused by tobacco consumption. Tobacco harm reduction describes actions

taken to lower the health risks associated with using nicotine, especially as delivered through

combustible tobacco, including but not necessitating complete abstention. These measures have

been argued to include; cutting down before quitting, smoking less, temporary abstention, switching

to non-tobacco nicotine containing products such as medically licensed nicotine replacement

therapies (NRT) or currently unlicensed products such as electronic cigarettes.

A Cochrane review carried out by Civljak et al. (2013) aimed to determine the effectiveness of

Internet-based interventions for smoking cessation. Their results suggest that some Internet-based

interventions can assist complete smoking cessation at six months or longer, particularly those which

are interactive and tailored to individuals. Innovative smoking cessation interventions delivered via

the Internet may be more attractive to young people and women who smoke, and also have the

advantage of potentially targeting a much wider audience. The potential effectiveness of Internet-

based smoking cessation interventions has been the subject of three recent systematic reviews

(Civljak et al. 2013; Myung et al., 2009; Shahab & McEwan, 2009). These reviews have shown that

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Internet-based interventions can help smokers to stop compared with brief written materials or no

intervention.

Many smokers are unable or unwilling to quit and therefore harm reduction strategies have been

the focus of recent research (Stead et al., 2007). The importance of developing quality interventions

for smoking cessation cannot be underestimated. However, as a secondary strategy, it may be

reasonable to seek ways to reduce harm from continued smoking for people who are not ready to,

or cannot quit. Data indicate that smoking reduction likely increases long term cessation rates

(Carpenter et al., 2004). The literature has examined smoking reduction among smokers who do not

plan to quit in the near future. These studies consistently found reduction increases the probability

of making a quit attempt later and of subsequent abstinence (Hughes & Carpenter, 2006). Reduction

is therefore a goal in itself. The harm reduction model takes a pragmatic approach to addiction,

acknowledging that some people will not be able to quit immediately, fully, or forever. If an

individual starts to smoke again after a period of abstinence, they can learn from the lapse and try

again until they succeed. The model also holds that small steps towards quitting are acceptable –

that a goal can be controlled use, rather than complete cessation. Reducing harm is a more effective

strategy than an intervention that does not work at all. For many diseases attributable to tobacco

use, reducing risk of disease by reducing exposure to tobacco toxicants is feasible (Stratton et al.,

2001). This conclusion is based on studies demonstrating that for many diseases, reducing tobacco

smoke exposure can result in decreased disease incidence with complete abstinence providing the

greatest benefit.

In the psychological literature self-efficacy has been established as an important construct in health

behaviour change, including smoking. Self-efficacy determines the appraisal of one’s personal

resources in stressful encounters and contributes to the forming of behavioural intentions. The

stronger their self-efficacy beliefs, the higher are the goals people set for themselves, and the firmer

their commitment to engage in the intended behaviour, even if failures mount. Self-efficacy is

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grounded in Social Cognitive Theory (SCT)(Bandura, 1977, 1986). There is ample evidence that self-

efficacy is a powerful determinant of behavioural intentions as well as of actual behaviour (Bandura,

1977, 1986, 1988, 1989, 1991). Its inclusion in theories on health behaviour, such as smoking, is

therefore warranted. It can be stated that the total effect of self-efficacy on health behaviours

exceeds the effects of any single variable (Schwarzer, 1992). Self-efficacy expectations predict future

success or failure in behaviour change programs, like quitting smoking (Schwarzer, 1992). Schwarzer

(1992) also claims that health education should focus on the improvement of self-efficacy in addition

to motivating people to behave in a healthier way. Psychological theory, such as SCT (Bandura, 1977,

1986) and the Theory of Planned Behaviour (Ajzen, 1991), and attributes of these theories, such as

self-efficacy, inform practice and intervention development. The construct of self-efficacy spans SCT

(Bandura, 1977, 1986), the Theory of Planned Behaviour (Ajzen, 1991) and the Trans-Theoretical

Model (Prochaska & Velicer, 1997).

In the present study Social Cognitive Theory (SCT) was used as a theoretical framework to examine

cognitions around smoking cessation. SCT explains how people acquire and maintain certain

behavioural patterns, such as smoking. The cognitive factors outcome expectations, self-efficacy and

intentions are important determinants of behaviour according to SCT (Bandura, 1986). Smoking

cessation self-efficacy is often defined as the ability to resist smoking in tempting situations, and

intentions are frequently framed in terms of motivation or readiness to quit (Prochaska et al., 1991;

Van Zundert et al., 2007). As such, SCT offers a theoretical framework to examine smoking

behaviour. A predictor which seems to play an important role in smoking cessation is self-efficacy to

resist smoking. Research has consistently shown that low self-efficacy is related to smoking relapse

among adults (Gwaltney et al., 2009). Conversely, high-self efficacy is associated with better

cessation outcomes.

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SCT suggests that before people are motivated to stop smoking and/or continue in any efforts to

remain smoke free, they have to believe they have the ability to do so (Bandura, 1977, 1986). Self-

efficacy expectations are important psychological determinants of smoking cessation (Dijkstra & de

Vries, 2000). Perceived self-efficacy is increasingly recognised to be important in health behaviour

change (Bandura, 1977; Schwarzer, 1992; Strecher et al., 1986; Staring & Breteler, 2004; Martinez et

al., 2010). In the field of smoking cessation, self- efficacy judgements have been shown to be

important determinants of abstinence. As some people find it very difficult to quit smoking

completely, it was hypothesised that a ‘softer’, ‘cut down to quit’ approach may lead to greater

smoking-cessation self-efficacy. Nicki et al. (1984) examined the usefulness of self-efficacy training in

combination with a ‘nicotine fading’ program (i.e. switching to progressively lower nicotine content

cigarettes) as compared to self-instructional training in combination with the same ‘nicotine fading’

program. Successive accomplishments in the treatment were interpreted as increasing competency

and mastery over cigarette smoking. According to Romanowich et al. (2009), behavioural theory

suggests that once a person’s smoking behaviour declines (as measured by breath carbon monoxide

(CO)) that person subsequently feels better about his or her chances of quitting. SCT may also

predict this correlation. Romanowich et al.’s (2009) analysis showed that decreases in breath CO

(reductions in smoking) predicted later increases in smoking cessation self-efficacy. SCT (Bandura,

1977, 1986), in particular the construct of self-efficacy, has led to the development of the current

intervention study.

Four psychological principles that suggest the gradual approach might be more effective than abrupt

cessation. Firstly, there is shaping, obtaining a target behaviour (lifelong cessation) by making

successive approximations of the target behaviour (gradual cessation produces progressively longer

periods of abstinence). Secondly, there is the cognitive psychology principle that completing a step

towards a goal (reducing cigarettes per day) increases self-efficacy which increases the likelihood of

completing the goal (cessation). Thirdly, the classical and operant conditioning principles that

decreasing the association of environmental cues and a behaviour weakens the behaviour (gradual

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smoking cessation typically uncouples cues from smoking). Finally, the psychopathology principle

that lowering drug intake reduces drug dependence increasing the ability to abstain completely

(Lindson et al., 2009). These psychological principles align well with the cognitive constructs of self-

efficacy, outcome expectations, and intentions of SCT.

Recent National Institute for Health and Care Excellence (NICE) public health guidelines (2013) call

for research and data on services offering harm reduction strategies. There is a clear gap in the

current literature on whether abrupt methods or gradual methods of smoking cessation can impact

smoking cessation self-efficacy.

The aim of this study was to see if a gradual reduction approach could be more effective than an

abrupt cessation approach in increasing smoking cessation self-efficacy. One intervention advocated

a complete cessation approach (STOP), the other advocated a gradual reduction approach (REDUCE).

The objective was to assess whether there was a difference between these two conditions in terms

of smoking cessation self-efficacy post intervention. It is important to address this problem as much

of the past research has led to conflicting and controversial results. Most research into interventions

on smoking cessation seem to focus on either complete cessation or harm reduction. However there

is limited research comparing the two approaches. It has been established that self-efficacy can

potentially have an impact on smoking cessation outcomes (Gwaltney, 2009). Increases in self-

efficacy have corresponded to increased success in smoking cessation. However, there is limited

research into whether different approaches to smoking cessation can lead to increasing self-efficacy.

There have been studies comparing abrupt and gradual approaches to smoking cessation (Etter,

2011) with complete cessation as an outcome. It is hypothesised that gradual cessation will be more

effective in increasing smoking cessation self-efficacy than abrupt cessation. It is also hypothesised

that the number of cigarettes smoked per day (CPD) will decrease significantly following

participation in these interventions. Confidence and motivation are hypothesised to increase

following participation in this intervention study. Research has shown that self-efficacy is an

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important predictor of smoking cessation (Gwaltney, 2009). However, to our knowledge, SCT has yet

to be used to assess whether abrupt or gradual approaches lead to greater smoking cessation self-

efficacy.

Method

Design

Randomised controlled trial with data collected at two time points; Time 1 (baseline) and Time 2

(follow-up). Participants were randomised assigned into one of two conditions, STOP (abrupt

cessation) and REDUCE (gradual cessation). Between-subjects and within-subjects design.

Participants and Procedure

A total of 100 participants signed up to the interventions (STOP (n=49) and REDUCE (n=51)). A total

of 29 participants completed follow-up questionnaires, STOP (n=16) and REDUCE (n=13).

In the STOP condition, ages ranged from 19 – 50 (M = 29.38, SD = 8.52). There were 24 males and 23

females in this condition. Two did not report gender. In the REDUCE condition, ages ranged from 18

– 54 (M = 31.02, SD = 10.72). There were 32 females and 16 males in this condition. Three did not

report gender.

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Participants were 18 years old or older and regular daily smokers (5 cigarettes or more per day).

Exclusion criteria stipulated that participants could not take part in the intervention if they were

already engaged with another smoking cessation intervention. All participants had fluent English, or

English of sufficiently high a level to complete the intervention. The study was approved by an ethics

committee at The School of Psychology, NUI Galway.

The intervention went live on the Lifeguide server on 7th May and recruitment took place between

7th May and 27th May. In order to recruit and randomise participants a group e-mail was sent out to

all registered students at NUI Galway on two separate occasions during these 3 weeks. A Facebook

page was also set up entitled Online Smoking Cessation Intervention Study at NUI Galway. This page

was promoted and received 487 likes. After randomisation the participants were directed to a host

site where they read study information, gave informed consent and completed all baseline

measures. Participants then proceeded with the fully-automated intervention which ran for 4 weeks

after their set quit date. Participants completed questionnaires online at two time points, in advance

of participation and within two weeks following participation. Participants were informed at

recruitment that they would be entered into a draw to win a 50 Euro One-For-All gift voucher if they

consented to take part in the study. A debriefing report was sent out to all participants (see

Appendix 7).

Intervention

This study adapted StopAdvisor (Brown et al., 2012), a four week tailored, interactive online

intervention which used the Lifeguide server (Yardley, 2011). StopAdvisor was developed on the

basis of PRIME theory, evidence, web-design expertise and user-testing. Development was

systematically informed by the PRIME theory of motivation (West, 2006). PRIME theory is an

integrative theory of motivation which recognises that behaviour is determined by multiple sources

on a moment-to-moment basis. PRIME theory describes the ways in which plans provide an

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overarching structure to our behaviour but in order to influence our responses, they need to

generate momentary impulses/inhibition which requires creation of motives (feelings of want or

need) through evaluations (positive and negative beliefs). This influence may compete with other

sources of motivation arising from internal states (such as drive states, arousal etc.).

There were 12 online interactive sessions which the participants’ engaged with after they set their

quit date. The content of the intervention consisted of a set of core behaviour change techniques

(BCT’s) as labelled within the ‘smoking taxonomy’ (Michie et al., 2011). The theme of the

intervention was an expert virtual Stop Smoking Advisor who was both a source of useful

information and a guide to help the smoker through the process of quitting using a structured quit

plan. Participants were offered twelve unique sessions and were given a week to get medication and

a week to set a quit date. The guidance they received involved specific advice and BCT’s on how to

address problems and plan for the future to minimise their occurrence. The StopAdvisor

intervention was slightly adapted for the STOP condition, and heavily adapted for the REDUCE

condition. In the STOP condition the time to get medication and time to set a quit date were

shortened from two weeks to one week. In the REDUCE condition, all references to ‘stop smoking’ or

‘quit smoking’ were changed to ‘reduce smoking’. In the REDUCE condition, the intervention was

also renamed ReduceAdvisor. Data was collected at two time points (baseline, follow-up). At

baseline participants completed a questionnaire that included demographic, smoking related,

confidence, motivation, and emotional information (see Appendix 1-2). At follow up participants’

completed a questionnaire that included smoking related, confidence, and motivation information

(see Appendix 3-4), plus an open ended feedback on their participation in the study question (see

Appendix 5-6).

Measures

Self-Efficacy Questionnaire -12 (SEQ-12)

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The primary outcome measure was score on the smoking cessation self-efficacy questionnaire (SEQ-

12). The SEQ-12 is a valid and reliable scale, which has applications in both research and clinical

settings (Etter et al., 2000) (see Appendix 1-2). SEQ-12 has been shown to fulfill criteria of content,

construct and predictive validity, was highly reliable in test-retest procedures, had a sound factorial

structure, a high internal consistency and was not biased by social desirability (Etter et al., 2000).

Scores on the SEQ-12 range from 12 – 60, with higher scores indicating higher self-efficacy.

Cigarettes per day (CPD)

The secondary outcome measure in this study was cigarettes per day (CPD), with measures of CPD

being taken at baseline and follow-up. All self-efficacy items and scales have been shown to be

strongly associated with the number of cigarettes smoked per day (Etter et al., 2000).

Confidence and motivation

Two other measures of note were confidence in ability to quit smoking and motivation to quit

smoking. The confidence measure was included in the original StopAdvisor intervention. The

motivation measure was added by the researcher. These were also measured at baseline and follow-

up. These variables were measured with the questions, “How confident are you that you will be able

to stop/reduce smoking?”, and, “How motivated are you to stop/reduce smoking?”. Participants

were given the opportunity to respond to these questions on a 7 point Likert-type scale ranging from

‘not at all’ to ‘very’. Confidence and motivation were included to assess whether the interventions

had an effect on confidence and motivation levels.

Statistical analysis

Calculation of sample size was carried out using G*Power for t-tests (means: difference between two

independent means (two groups)). The type of power analysis was a priori to compute required

sample size – given α, power, and effect size. For a two-tailed test with an effect size of 0.5, an α

error probability of 0.05, and power of 0.8 a total sample size of 128 was calculated (64 in each

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group) (noncentrality parameter = 2.82, critical t = 1.97, Df = 126, actual power = 0.80). 64

participants in each arm of the trial (128 total) was the target sample size.

The primary analyses used an intention-to-treat approach. The primary outcome variable

(dependent variable) was score on the SEQ-12 questionnaire. The secondary outcome variable was

cigarettes per day (CPD). To test for differences in the primary outcome variable, a mixed factorial

analysis of variance (ANOVA) was used, in which the between subjects factor was group (STOP,

REDUCE), and the within subjects factor was time-point with two levels (baseline, follow-up). Mixed

ANOVA’s were also carried out on confidence and motivation scores to see if there was a change in

score over time or between groups.

RESULTS

Descriptive statistics

The mean age for the sample (n=29, 12 males, 17 females) was 31.72 years (SD=9.97, range 19-54)

Participants in STOP completed a mean of 3.31 (of a total of 12) sessions (SD= 3.96). Participants in

REDUCE completed a mean of 6.15 (of a total of 12) sessions (SD=5.06).

Only 2 participants in the STOP condition completed all 12 sessions and 5 participants in REDUCE

completed all 12 sessions.

Table 1 shows scores for the SEQ-12 and CPD at baseline and follow-up.

Figure 1 shows the flow of participants through the stages of the intervention.

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Figure 1. CONSORT flow diagram of progress through stages of the randomized trial.

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Allocation

Enrollment

Follo

w u

pAnalysis

Assessed for eligibility

(n = 100)

Randomized (n = 100)

Allocated to STOP intervention

(n = 49)

Allocated to REDUCE intervention

(n = 51)

Lost to follow up

(n = 33) (did not complete post-intervention questionnaire)

Lost to follow up

(n = 38) (did not complete post-intervention questionnaire

Analyzed (n = 16) Analyzed (n = 13)


Table 1

Means and standard deviations for scores on the SEQ-12 and cigarettes per day (CPD) at baseline

and follow up.

SEQ CPD

Baseline Follow-up Baseline Follow-up

M SD M SD M SD M SD

STOP 30.00 9.21 33.25 10.51 9.69 4.90 7.19 6.18

REDUCE 33.85 13.55 37.15 8.37 11.92 6.95 6.00 7.95

Means and standard deviations for confidence and motivation scores are summarised in Table 2.

Scores for confidence and motivation range from 1-7, where 1 = not at all and 7 = very.

Table 2 Mean scores for confidence and motivation at baseline and follow up

BASELINE FOLLOW UP

CONFIDENCE MOTIVATION CONFIDENCE MOTIVATION

M SD M SD M SD M SD

STOP 4.25 1.98 5.56 1.37 4.18 2.07 4.75 1.57

REDUCE 4.92 1.44 6.46 0.97 5.31 1.80 5.39 1.89

Mixed ANOVA

Five one way ANOVA’s were conducted on SEQ, CPD, confidence, motivation and gender to see if

there were significant differences in study variables at baseline. All groups were similar at baseline

ensuring randomisation was successful.

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A 2 x 2 mixed ANOVA was conducted to examine whether participants scores on the SEQ-12

questionnaire differed before and after an experimental manipulation, depending on which

experimental group they were in. The within-subjects factor was time with two levels (baseline,

follow-up) and the between subjects factor was experimental group also with two levels (STOP,

REDUCE).

Analyses revealed no effect for time (F(1,27) = 1.16, p = .29, η2 p = .04). There also was no main effect

for group (F(1,27) = 2.45, p = .13, η2 p = .08). The means and standard deviations are presented in Table

1. The time by group interaction also had no effect (F(1,27) = .00, p = .99, η2 p = .00).

A 2 x 2 mixed ANOVA was conducted to examine whether participants cigarettes per day (CPD)

differed before and after an experimental manipulation, depending on which experimental group

they were in. The within subjects factor was time with two levels (baseline, follow-up), and the

between subjects factor was experimental group also with two levels (STOP, REDUCE).

Analyses revealed a main effect for time (F(1,26) = 22.84, p = .00, η2 p = .47) where CPD was less post-

intervention (M = 6.68, SD = 6.88) than pre-intervention (M = 10.64, SD = 5.85). There was no main

effect for group (F(1,26) = .05, p = .82, η2 p = .00). There was no effect for the time by group interaction

(F(1,26) = 3.76, p = .06, η2 p = .13). Figure 2 shows the decrease in CPD over time.

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Figure 2. Decrease in CPD smoked over time.

A 2 x 2 mixed ANOVA was conducted to examine whether participants’ confidence scores differed

before and after an experimental manipulation, depending on which experimental group they were

in. The within subjects factor was time with two levels (baseline, follow-up), and the between

subjects factor was experimental group, also with two levels (STOP, REDUCE).

Analyses revealed no main effect for time (F(1,27) = .20, p = .66, η2 p = .01). There was also no main

effect for group (F(1,27) = 2.29, p = .14, η2 p = .08). The time by group interaction also had no effect

(F(1,27) = .38, p = .54, η2 p = .01). The means and standard deviations are displayed in Table 2.

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A 2 x 2 mixed ANOVA was conducted to examine whether participants’ motivation scores differed

before and after an experimental manipulation, depending on which experimental group they were

in. The within subjects factor was time with two levels (baseline, follow-up), and the between

subjects factor was experimental group, also with two levels (STOP, REDUCE).

Analyses revealed a main effect for time (F(1,27) = 13.46, p = .00, η2 p = .33) where motivation scores

were lower at follow up (M = 5.03, SD = 1.72) than at baseline (M = 6.00, SD = 1.27).

There was no main effect for group (F(1,27) = 2.43, p = .13, η2 p = .08). There was also no main effect for

the time by group interaction (F(1,27) = .26, p = .61, η2 p = .01).

As shown in Figure 3 motivation scores decreased over time for both groups.

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Figure 3. Motivation scores for both groups over time.

An open-ended question, “Please leave any comments, positive or negative, about the intervention

in the box below. If you did not complete the intervention, could you please say why? Suggestions

for improvements also welcome.” was included in the post-intervention questionnaires (see

Appendix 3-4).

Discussion

The present study used Social Cognitive Theory (SCT) to assess whether an abrupt or gradual

approach to smoking cessation had an impact on cognition and smoking behaviour. The results

showed that there were no significant differences over time or between groups on the levels of

smoking cessation self-efficacy of the participants. However, there was a significant difference over

time for cigarettes per day (CPD) with participants smoking less post-intervention than pre-

intervention. There were no significant differences over time for confidence levels, however, it was

found that motivation levels decreased significantly over time.

The first hypothesis, that a gradual approach to smoking cessation would be more effective than an

abrupt approach in increasing smoking cessation self-efficacy was not supported. This hypothesis

was based on Social Cognitive Theory (SCT), shaping, cognitive psychology, classical and operant

conditioning, psychopathology, and the fact that there were behaviour change techniques

embedded in the online interventions that were designed to increase self-efficacy. Our finding was

in contrast to what was expected. The reason for this may be that participants did not engage fully

with the online interventions and their motivation to quit smoking appeared to decrease over time.

This finding was in line with a Cochrane review by Lindson-Hawley et al. (2012) which found that

neither reduction nor abrupt quitting had superior quit rates. A trial carried out by Etter et al. (2009)

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also produced a similar conclusion. They found that starting nicotine gum treatment 4 weeks before

the target quit date and gradually reducing was no more effective than starting treatment on the

quit date.

The second hypothesis, that cigarettes per day (CPD) would decrease over time was supported. CPD

decreased significantly over time in this study but not as a function of group. This finding suggests

that both interventions were effective at decreasing smoking behaviour. Using medication or

nicotine replacement therapy (NRT) was a significant part of the intervention. Stead & Lancaster

(2007) found that using NRT roughly doubled the odds of reducing CPD by 50% or more.

The third hypothesis, that confidence in ability to quit/reduce smoking would increase over time,

was not supported. There were no significant differences over time or by group in confidence scores,

indicating that the intervention did not have an impact on confidence levels. Research has found

that confidence in the ability to quit is a critical component in cessation. Hendricks et al. (2010) state

that interventions for addiction may produce abstinence in part by increasing individuals’ confidence

in their ability to quit. They found that self-efficacy, accounted for 61% to 83% of the total effect of

treatment on abstinence. Confidence in ability to quit and self-efficacy may be related. Thus no

effect in the scores of self-efficacy in this study may also be related to no effect in the confidence

scores.

The fourth hypothesis, that motivation scores would increase over time was also not supported. In

fact, the opposite was found, motivation was found to decrease significantly over time, indicating

that participants became less motivated as they progressed through the intervention. This lack of

motivation can be seen in the flow of participants through the intervention (see Figure 1), the fact

that participants did not engage fully with the intervention, and there was no effect for the first

hypothesis. A recent review on predictors of outcomes on attempts to quit found that motivation to

quit only predicts how likely a smoker is to attempt to quit, not how successful that attempt will be

(Vangeli et al., 2011).

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Limitations

All results should be interpreted with caution because of the small sample size.

The major limitation of this study was the low rates of participation and engagement with the

interventions. The validity and usefulness of internet interventions for smoking cessation must be

called into question. More evidence is needed to determine if Internet interventions can help people

to stop smoking. Graham et al. (2011) found that combined Internet and telephone treatment

outperform static and dynamic internet interventions for smoking cessation. The StopAdvisor

intervention is interactive and tailored to the individual. The participant engages in sessions with a

virtual smoking cessation advisor. However, as Graham et al.’s (2011) study suggests, human contact

combined with internet interventions may lead to better outcomes. Internet interventions alone

may be limited in what can be achieved.

As well as the limitations of the online interventions, this study had several other limitations. Firstly,

the sample size was small. Only 29 participants were included in the final analysis. The recruitment

of a larger and more diverse sample is needed. Approximately 70% of participants were lost to

follow-up. One reason for this may be that there was a time delay between participants finishing the

intervention and the post-intervention questionnaires being sent out. That is, there was variability in

follow-up with participants completing post-intervention questionnaires up to two weeks after they

had finished the intervention. Secondly, as well as being small the sample was relatively

homogenous, almost entirely being made up of white Irish students. The findings would need to be

replicated with other samples to ensure generalizability. Thirdly, self-efficacy was measured at two

time points in this study. Previous studies among adults have demonstrated that self-efficacy is a

dynamic construct and that day-to-day variations in self-efficacy play an important role in smoking

cessation (Shiffman et al., 2000; Stuart et al., 1994). Therefore, the validity of measuring self-efficacy

at two time points may be questioned. It is suggested that daily measures of self-efficacy be taken to

examine how self-efficacy may fluctuate over time. The study would have been further improved by

a longer follow-up period and data could have been collected at three or four time points for follow

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up, instead of two. Fourthly, there were no independent biological markers or objective measures of

smoking reduction or cessation included in the study. Finally, participants chose to take part in the

study, therefore there may have been a bias due to self-selection or response bias. More successful

ways of engaging with participants must be found. Only 7 out of 100 participants completed all 12

sessions of the intervention. Perhaps text messages, phone calls, or other live person to person

support could enhance the intervention and lead to better higher engagement. Different outcomes

may have resulted had the participants engaged more with the intervention.

Implications for practice exist: if there is no difference between abrupt and gradual methods

therapists should probably determine smokers’ preference for either abrupt or gradual cessation

and offer both treatment options. Those who used the gradual method may be less likely to receive

professional support, since gradual cessation is not recommended by most treatment guidelines

(Fiore, 2008)

Although it was found that there were no differences between abrupt and gradual methods in terms

of increasing smoking cessation self-efficacy, it has been suggested that method used to quit (abrupt

or gradual) does matter, but only in those who express a strong preference for either method (Etter,

2011). Future research could address this point by assessing preference. Future research could also

examine ways in which motivation to quit could be initiated and maintained over the course of an

intervention. In terms of theoretical development, future research should address how SCT, in

particular the construct of self-efficacy, can be employed to inform the development of successful

interventions. The majority of studies have complete smoking cessation as the main outcome. No

studies were found that compare abrupt and gradual approaches in terms of smoking cessation-self-

efficacy. Further research is required to understand exactly how method used to quit (abrupt or

gradual) can impact self-efficacy.

22


In conclusion, although participants were motivated to take part in the intervention, this initial

motivation was not maintained. In order for future online interventions to be successful, better ways

of engaging with participants need to be found. In SCT self-efficacy is assumed to play a central role

in smoking cessation (Gwaltney et al., 2009). Methods for increasing participants’ self-efficacy need

to be found. The results of this study showed a practical decrease in smoking behaviour (CPD), but

highlight the need for a closer examination of the role of self-efficacy, confidence and motivation in

smoking cessation.

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Appendix 1 – StopAdvisor Baseline Questionnaire

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Appendix 2 – ReduceAdvisor Baseline Questionnaire

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Appendix 3 – StopAdvisor Follow – Up Questionnaire

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Appendix 4 – ReduceAdvisor Follow – Up Questionnaire

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Appendix 5 – StopAdvisor, open responses to the study

16) Please leave any comments, positive or negative, about the intervention in the box below. If you did not complete the intervention, could you please say why? Suggestions for improvements also welcome.

Thank you for completing this questionnaire

Couldn't complete it as went away on holidays, and a couple of life events happened back to back, so will have to try again. Also much harder having a partner who smokes. I'd say if they weren't I would have had a much better chance

I've quit for good

I found that once I smoked again I lost interest in trying. I think I need to be fully 100% sure that I want to smoke before I will manage to quit. you're welcome

I did not complete the intervention this time unfortunately although this was a great help. This is my 3rd time to try to quit smoking, I'm going through a very stressful time between moving countries twice in a year/studying law/etc etc all excuses know but I am certain the next time I attempt to quit will be the last! Thank you

I didn't complete the intervention because the week that I was supposed to quit ended up being quite stressful and it slipped my mind. It would've been an extra stressor, I wouldn't have been able to cope.

Thank you for having me! I will try to quit eventually.

The intervention was providing a level of support which i found helpful when I attempted to stop smoking. As soon as I started again the I supristed that the intervention stopped. It was a bit of a let down because I saw it as a relapse/error on my part, not a reason to abandon the project.

I didn't complete the intervention because, I ended up moving around and generally life got pretty busy. I was away a lot and not home often to fully benefit from the intervention.

I wasn't motivated enough to quit

A helpline I think is needed, when I have cravings and Im home alone I will smoke, it is a lot easier to distract yourself when you have someone to distract you. A buddy system might also work, a person also trying to quit that you keep in contact with on a daily basis.

I thought the programe was good and enjoyed my few days of success but unfortunately my parntner's mother died, there was a wake and funeral coupled with me working in between and i used this as an excuse to smoke. I would have liked a chance to hop back on once I had resumed smoking however to encourage me to stop again very quickly. Thanks though. I'll try again sometime when I am more determined.

I Did complete,but now it's the case of Not wanting to smoke-over needing to smoke. No Problem.

I have started using an e-cigarette. I'm trying tio use it sparingly so as to wean myself off the nicotine.

Appendix 6 – ReduceAdvisor, open responses to the study

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16) Please leave any comments, positive or negative, about the intervention in the box below. If you did not complete the intervention, could you please say why? Suggestions for improvements also welcome.

Thank you for completing this questionnaire

Thank you for your help

glad i took part, overall sense of achievment on being a reduced smoker with aim to get completly off them , some responses were generic and repetitive when stating i had a puff, but still felt supported and encouraged too complete the survey

The intervention seemed to be aimed at people who wanted to quit- I thought it was just to cut down on the number smoked

I completed the programme. I was a little disappointed, though. The term'reduction' assumed that I was totally giving up smoking. Further, the intervention recommended medical intervention only, despite me saying that I didn't want to use medical intervention.

was unable to access interventions but have not smoked for five days and am feeling very good

Did not complete as website cut me off when i entered that i had not reduced smoking

very often the links were broken, and the questionaire never changed...it wasn't to useful

Unfortunately I did not have time to complete the intervention due to a change in job & house.

Appendix 7 – Debriefing Report

School of Psychology

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National University of Ireland – Galway

DEBRIEFING REPORT

Thank you to all the participants who took part in this study. In this sheet I briefly tell you about what we found. If you would like further information please contact me at: [email protected]

Project title: Comparing the effectiveness of two different approaches to smoking cessation in increasing smoking cessation self-efficacy. A comparison of two online interventions.

Researchers name: Riyad El-Moslemany

Supervisors name: Dr. Molly Byrne

Purpose of research: To see if a gradual approach to smoking cessation could be more effective than an abrupt approach in increasing smoking cessation self-efficacy.

General Procedure: The procedure involved recruitment of participants for a 4 week randomised controlled trial of two online interventions. One intervention advocated complete cessation (STOP), the other advocated gradual reduction (REDUCE).

General Findings: The results revealed that there were no significant differences between the two interventions in terms of their impact on scores on the smoking cessation self-efficacy questionnaire (SEQ-12). Cigarettes per day (CPD) decreased over time following participation the interventions for all participants If you wish to continue in your efforts to quit smoking please consult the HSE website www.quit.ie or call The National Smokers Quitline on Freefone 1800 201 203.

Researcher signature:

Supervisor signature:

Appendix 8 - PARTICIPANT INFORMATION SHEET

1 Title of Project:

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http://www.quit.ie/


Study of two interventions for smoking cessation.

2 InvitationYou are invited to take part in a research study. Before you decide, it is important that you understand why the research is being done and what it will involve. This Participant Information Sheet tells you about the purpose, risks and benefits of this research study. If you agree to take part, we will ask you to sign a Consent Form. If there is anything that you are not clear about, we will be happy to explain it to you. Please take as much time as you need to read this information. You should only consent to participate in this research study when you feel you understand what is being asked of you, and you have had enough time to think about your decision. Thank you for reading this.

3 Purpose of the study

This study is concerned with smoking cessation. The aim of this project is to see if different approaches to giving up smoking can have different results. The duration of the intervention will be four weeks. The general subject of this research is smoking cessation. You have been asked to participate as you are a daily smoker (5 cigarettes or more per day) and are aged eighteen or over. There will be many other participants in this study, the total figures required are being calculated and it depends how many people respond to the invitation to take part in the study how many people will be included. You have been identified and contacted through the NUI registered students mailing list, the Health Promotion Service within the college or from a poster advertising the study.

4 Taking Part – What it Involves

Taking part in this study will involve taking part in an online intervention, over a four week period. You will be expected to engage fully with the intervention. You will be expected to record your smoking behaviour, cigarettes smoked per day (CPD) and any aids you may use, such as patches, gum or electronic cigarettes, to help you to quit. All of the information you will be required to record will be part of the intervention and completed online.

Do I have to take part?It is up to you to decide whether or not to take part. If you do decide to take part you will be given this Information Sheet to keep and be asked to sign a Consent Form. If you decide to take part you are still free to withdraw at any time and without giving a reason. A decision to withdraw at any time, or a decision not to take part, will not affect your rights in any way.

What will happen to me if I take part?

If you agree to take part in this study you will have to fill out a questionnaire at the beginning, monitor and record your smoking behaviour over four weeks, and fill out a questionnaire at the end.

How long will my part in the study last?

This research will last for eight months, however you will be involved for four weeks. You may be contacted briefly once or twice online during the intervention by the researcher to see how you are progressing and if you are having any problems.

What are the possible benefits in taking part?

Individuals who participate in this study may experience both psychological and physical benefits. Participants may experience a greater belief that they can give up smoking as a result of this study. Participants may also experience general health benefits as a result of giving up or reducing smoking.

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What are the possible disadvantages and risks of taking part?

The risks to participants’ well-being/safety include those risks that are associated with giving up smoking. Participants may suffer from nicotine withdrawal symptoms and may experience physical or mental distress, stress or anxiety connected to these withdrawal symptoms. The participants will be expected to engage with an online intervention over four weeks. This places demands on the time of the participants’ and may be considered as an inconvenience. You will not be provided with any support or treatment once the intervention is over.

What happens at the end of the study?

When all participants have been tested (this should be within 6-8 months of your participation), you will receive a summary of one or 2 pages of the main findings. While it could be up to 2 years before final results are published, we would be pleased to include you on an address list to receive publications arising from the study. Only general findings will be reported, without reference to identifiable individual results.

What happens if I change my mind during the study?You are entitled to change your mind about participating in this at any time without disadvantage or penalty.

Who do I contact for more information or if I have further concerns?

You can contact Riyad El-Moslemany at [email protected] if you need more information or if you have any further concerns

If you have any concerns about this study and wish to contact someone in confidence, you may contact: The Head, School of Psychology, National University of Ireland, Galway.

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mailto:[email protected]


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dissertation final draft 2108

Documents

smoking cessation stop

introduction smoking

keywordssmoking cessation

cessation method

participants data

gradual interventions

online interventions

decreasing smoking behaviour