|Year : 2021 | Volume
| Issue : 2 | Page : 103-109
Application of Health Behavioral Models in Smoking Cessation – A Systematic Review
Karthikayan Ravi1, K Indrapriyadharshini2, PD Madankumar3
1 Postgraduate Student, Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
2 Senior Lecturer, Department of Public Health Dentistry, Karpaga Vinayaga Institute of Dental Sciences, Kanchipuram, Tamil Nadu, India
3 Head of the Department, Department of Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||18-Nov-2020|
|Date of Decision||18-Feb-2021|
|Date of Acceptance||12-Apr-2021|
|Date of Web Publication||14-Jun-2021|
Department of Public Health Dentistry, Ragas Dental College and Hospital, No: 191, East Coast Road, Uthandi, Chennai - 600 096, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Smoking is a significant risk factor for morbidity and mortality. Health education by health promotion is such a gauge to control tobacco epidemic at both national and multinational levels. Objectives: The objectives of the study were to systematically review the literature to identify models for health behavior change and evaluate evidence for their effectiveness in smoking cessation. Methods: A systematic review of the literature identified four peer-reviewed studies describing two smoking cessation behavioral interventional models (transtheoretical model [TTM] and health belief model [HBM]) between 2008 and 2018. Electronic databases MEDLINE (PubMed) and Google Scholar and Trip database were carried out. There were two randomized controlled trials and two nonrandomized controlled interventional studies. There was a high degree of homogeneity of design, definition of smoking and smoking abstinence, and implementation, followed by comparison of studies. All included studies have evaluated outcome by stage of changes (component of TTM model) and therefore show the reduction of smoking rate. All studies did not have blinding of study participants, leading to a higher risk of bias in the outcome. Results: There was a statistically significant difference between TTM-based interventional group and control group in smoking cessation rate. While comparing HBM- and TTM-based behavioral counseling, there was no statistically significant difference in smoking cessation rate. Conclusion: Both HBM- and TTM-based trainings were found to have positive effects on both smoking cessation and progression between the stages.
Keywords: Health behavioral model, smoking cessation, systematic review
|How to cite this article:|
Ravi K, Indrapriyadharshini K, Madankumar P D. Application of Health Behavioral Models in Smoking Cessation – A Systematic Review. Indian J Public Health 2021;65:103-9
|How to cite this URL:|
Ravi K, Indrapriyadharshini K, Madankumar P D. Application of Health Behavioral Models in Smoking Cessation – A Systematic Review. Indian J Public Health [serial online] 2021 [cited 2021 Jul 30];65:103-9. Available from: https://www.ijph.in/text.asp?2021/65/2/103/318358
| Introduction|| |
Tobacco epidemic is one of the most consequential public health menaces that the world has ever faced, causing 9 million deaths per year. It is approximated that, by the end of 2030, the number of deaths caused by smoking will extend to more than ten million of which 70% will be in developing countries. According to the recent Global Adult Tobacco Survey Fact Sheet, in India around 19.0% of men, 2.0% of women presently smoke tobacco. The prevalence of smoking in our country, based on a meta-analysis, is 13.9% (21.7% in males and 3.6% in females).
The pattern of active and passive smoking is the foremost seed of preventable diseases and death universally and is a vital health problem among both adults and children., Quitting smoking is fortunate for health predominantly for smokers who quit ahead of the age of 35 years as their mortality rates are related to those who have never smoked.
The World Health Organization has taken vital venture at micro and macro levels to control the tobacco epidemic. The attempt to encourage smoking cessation needs to be part of a much wider national tobacco control strategy that spotlight prevention, it is explicit that the greatest gains in reducing tobacco-caused morbidity and mortality. There are numerous entrenched tools for smoking cessation, including a range of pharmacotherapies like nicotine replacement therapy, bupropion, varenicline and behavioral approaches like group or individual counseling, self-help materials.
According to Daly, a simple description of human behavior proceeds from the accession/acquisition of knowledge. It leads to the attitudes, beliefs, and values which in turn results in skills or actions performed. According to Sullivan, any health circumstances alter the behavior and vice versa. In this circumstance, individuals ascribe and behavioral patterns recite the health status. In disparity, social, economic, and environmental status also plays a definite role. Since these factors are out of control of health professionals, a realistic approach to prevent the disease can be accomplished through health education which is used to provide information and bring changes in human behavior.
Health education by health promotion is an effective gauge to control tobacco epidemic at both national and multinational levels. It mainly stresses on behavioral, cultural, social, and economic factors as decisive of disease causation. Effective behavioral intervention approach should be theoretically handled, targeted at peculiar behaviors, and focused on endangered and high-risk groups.
The present research states that health behavior models appraise more evidence-based approaches to mature personal skills and health literacy among individuals across health education. According to Prochaska and Velicer, interventional methods were more effective than the noninterventional in behavior change studies. Studies on model-based health behavior modification have shown positive results when compared to other traditional health education models which can be applied at individual level, and suitable in a dental clinical setting. These behavior models raffle on psychological theories of self-efficacy, motivation, counseling, and behavior change. Such models have been utilized for smoking cessation with some success.
Previous literatures exit on health belief model (HBM)- and transtheoretical model (TTM)-based behavioral approach as an intervention for smoking cessation. HBM is a fine model for stamping problem behaviors that extract health-related concerns. It defines the relationship between a person's beliefs and behaviors and the effects of individual motivation on health behaviors at decision-making level. Further HBM has been used to help in designing messages that are likely to persuade an individual to make a healthy decision.,,
The TTM-based practices, which were first detailed by Prochaska and DiClemente, identify the relationships between stages of change (SOC), process of change, perceptions of benefit and loss of decisional balance or change, self-efficacy in the behavior change, and encouraging factors for smoking cessation.
The aim of this study was to systematically review the literature to identify models for health behavior change and evaluate evidence for their effectiveness in smoking cessation. This work will throw light on the role of behavioral models for smoking cessation in clinical encounters.
| Materials and Methods|| |
A systematic review of health behavioral models in smoking cessation was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered with the Prospective Register of Systematic Reviews (reg. number: CRD 146452).
Key question of this review was – do health behavioral models have any role in smoking cessation among smokers?
The review was conducted using the PICO analysis. Population – Smokers above the age of 18 years. Interventions – Health education as a behavioral intervention using theoretic/scientific models or approaches. Outcome – Changes in smoking behavior.
The following inclusion and exclusion criteria were applied for selecting the studies:
- Studies evaluating the effectiveness of individual and interpersonal health behavioral models on smoking cessation
- Studies measuring the effectiveness of health behavioral models on smoking cessation over a minimum time frame of 6 months
- Original research articles conducted among adults aged above 18 years based on individual and interpersonal theoretical models
- Systematic reviews, meta-analyses, and randomized and comparative studies were included
- Articles published only in English language
- Studies published between 2008 and 2018 (10 years) only were included.
- Narrative reviews, editorials, letters, articles identified as preliminary reports when results are published in later versions, articles in abstract form only, literature from conference proceedings, dissertations and government reports, and unpublished articles were excluded
- Studies which only present observational data or only provided treatment as their intervention
- Studies published before 2008 (non-English publications) were excluded.
An electronic search in MEDLINE (PubMed) and Google Scholar and Trip database was carried out by using Medical Subject Headings terms “health behavioral model,” “Tobacco,” “Smokers,” “smoking cessation” and “health behavioral modification approaches,” “behavioral intervention,” “health education” and “psychological models, AND/OR.” Relevant cross-references were followed up. The search dates were limited to 2008 onwards. All electronically identified records were scanned by title, abstract, and/or keywords by both authors, and full-text articles were included. Resulting studies from this search were subjected to primary review and grouped based on the type of intervention used: (i) studies using self-efficacy model, (ii) studies based on TTM, (iii) studies based on self-regulatory model, and (iv) HBM. Contact with an expert in the field was also established in order to ensure that no relevant studies were missed. The reference lists of all eligible studies were also hand searched for additional relevant studies.
Two calibrated reviewers screened the titles and abstracts (when available) of all identified studies independently. Relevant titles, keywords, and abstracts were assessed. Both the authors reviewed the studies retrieved from the literature search. Studies were included based on the inclusion criteria. Once the publication was considered by either author to meet the inclusion criteria, the full-text article was obtained and reviewed. Disagreement between two independent reviewers was sorted out by discussion. A total of 133 articles were assessed after reading titles. A total of 81 articles were excluded after reading abstract. Full-text articles were retrieved for 52 studies. Finally, four studies were selected based on the eligibility criteria.
Data extraction process
Data extraction was completed independently by the two reviewers using a specifically designed data extraction form. Quality assessment criteria to evaluate the studies were decided by two review authors in accordance with CONSORT guidelines. Data were collected on participant characteristics (sex and age), sample size, study type, methodological description, follow-up, theoretical construct/intervention model used measurement of tobacco cessation, results/outcome measures.
Methods to appraise the quality of individual studies
Each study was assessed using the evaluation method described in the Cochrane Handbook for Systematic Reviews (Higgins and Green. Cochrane reviewers handbook 2009). The quality assessment of the included trials was undertaken independently by two reviewers. The domains evaluated were random sequence generation, allocation concealment, assessor blinded, dropouts, and risk of bias. Each domain was classified as having a low, high, or unclear risk of bias. Thus, the overall level of risk for each study was subsequently classified as low (if it did not record a “yes” in three or more of the four main categories), “moderate risk” of bias (if two out of four categories did not record a “yes"), “low risk” (if all the four categories recorded were adequate), and “unclear (unclear risk of bias for one or more domains).
Rationale for pooling results of included studies
All the included studies had a similar duration of follow-up (6–12 months) and consistent outcome measures by HBM based and TTM component based. Hence, results have been pooled and reviewed to compare quantitatively.
| Results|| |
Study selection process
The search strategy identified 3633 studies according to the keyword search. All of them were screened with the help of abstracts and titles. Fifty-two studies were found to be eligible for this review and further assessed. Out of 52 studies, 4 studies were included. Twenty-eight studies were regarded as irrelevant to the review. Twenty studies did not fulfill the inclusion criteria and hence excluded. The systematic review of four articles was conducted based on eligibility criteria.
Included studies were conducted and published between 2008 and 2018. Study designs included two randomized controlled trials, and two nonrandomized controlled interventional studies, [Table 1].
|Table 1: Distribution of the studies according to the type of theory/model or approach used in the intervention for each group|
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In three out of four included studies, participants were recruited based on whether they would volunteer to participate in the study,,, except one study which used previous trial data to recruit the participants. All studies included participants who smoked cigarettes or tobacco only without using any form of smokeless tobacco. The mean number of cigarettes per day in included studies was 19.5, 13.5, and 16–20 in studies done by Aveyard P et al., Koyun A et al., and Bakan BA et al., respectively, and the remaining one study made no mention regarding the cigarettes consumed per day. Study sample size of all the included studies ranged from 60 to 2471. The age of the participants ranged from 18 to 41 years. Most participants (range: 55.7%–100%) were female; one study included only female participants.
The outcome definition of smoking cessation was highly variable [Table 2]. One out of the four studies used Fagerstrom Nicotine Dependence Scale to define smoking cessation, in addition to SOC. One study used a number of cigarettes per day to confirm self-reported smoking status. All the studies used uniformly TTM components (stage of change) to ascertainment of smoking status.,,
TTM-based health behavioral counseling was the most common form of intervention among all the studies,, except the study done by Bakan and Erci who compared transtheoretical- and HBM-based health behavioral counseling among smokers.
Three out of four included studies had 12-month intervention follow-up,, except one study which had a 6-month follow-up. All the included studies had 3–4 counseling sessions across 6–12 months of smoking cessation. There was no correlation between the number of sessions and the success of smoking cessation, although this was difficult to evaluate given the varied study designs.
Transtheoretical model-based intervention
All the included four studies used TTM-based behavioral counseling as an intervention (Bakan and Erci compared health belief and TTM approach).,,, Koyun and Eroğlu stated that there existed no statistical difference between TTM-based intervention and control groups; smoking cessation rates were 2.6% in the control group and 23.7% in the intervention group at the 6-month follow-up period. However, Gungormous Z et al. found that there was a statistically significant difference between the groups in the SOC alone and there were no significant differences found between the Process of Changes Total Score (POC), Decisional Balance Scale (DB), Temptation Score, and Self-Efficacy Score (SES). Bakan BA et al. found that after the training in the TTM group, there was an increase in the PCS scores and SES scores and a decrease in the DBS scores. No significant differences were detected between the pretest and posttest in terms of the mean scores belonging to the Self-Efficient Scale and the Temptation Scale. Fagerstrom score in the TTM-based intervention group before training was 2.34 ± 1.5 and after training decreased to 2.16 ± 1.6, but it was not statistically significant. After the training, it was found that there was an increase in the negative attitudes about smoking mean scores in both the groups. The mean score of the HBM group was found to be higher than that of the TTM group. The difference was found to be statistically significant (P < 0.05). Aveyard et al. found that TTM intervention-based group arms were slightly but not significant to make positive stage changes than the control arm. The mean change score in the controls was 0.39 and in the TTM group was 0.46.
Health belief model-based intervention
A study done by Bakan and Erci compared HBM and TTM approach for behavioral counseling. The mean value for Fagerstrom score in the HBM-based group before training was 2.69 ± 1.5 and after training declined to 2.35 ± 1.5. Process of Behavioral Change Scale mean score was lower in the HBM-based group compared to the TTM group. Posttraining HBM-based group had no significant differences in the Self-Efficient Scale and the Temptation Scale. DBS mean scores displayed that according to the posttest measurement done after the training, there was a decrease in the positive attitudes about smoking mean scores in both the groups.
Appraisal of individual studies' quality
Both the authors had independently done the assessment of the quality of studies included, using the Cochrane Handbook for Systematic Reviews (Higgins and Green. Cochrane reviewers handbook 2009) [Table 3]. Two studies had low risk for bias while others had unclear risk of bias, as their participants who were not randomized to the intervention [Figure 1]. All included studies did not blind the study participants or study personnel in assignment of intervention and during data collection, leading to a higher risk of bias in the outcome. However, it is to be noted that the nature of this behavioral intervention makes it difficult to blind participants and clinicians to the intervention.
|Figure 1: Risk of bias graph: Review author's judgment about risk of bias item presented as percentages across all included studies.|
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| Discussion|| |
In this present review, all included studies,,, had evaluated outcome by SOC (component of TTM model). In the included studies, when compared to the control group, smoking status, SOC score, and process of changes (POC) demonstrated better scores in the intervention group. In all included studies, after an average 6–12 months' follow-up, quit in smoking status, SOC, POC, SE, and DB scores were improved and the Temptation Scale score was reduced in the group training by TTM-based behavioral intervention.,,, Maximum scores in process of the Behavior Change Scale designate that towering success in accordance to the behavioral change. An increase in the score of the Self-Efficacy Scale denotes that robustness of taking stand hostile to previous behavior and lower score of the Temptation Scale signifies that low disposition to recommence the previous behavior. In the study done by Bakan and Erci, HBM and TTM approach of behavioral counseling in tobacco cessation were compared, and authors propounded that HBM and TTM-based training were found to have indubitable effect on both continuing action and smoking cessation for 6 months or more. TTM-based training seems to be a more emphatic effect in smoking cessation than HBM model.
As stated by HBM, insight into an action related with perceived threat in relation to health due to smoking and perceived benefit in accordance to accomplishment of protective health behavior (if quits smoking), internal and external rewards impart with the conceding of the behavior and self-efficacy was the reason for improved smoking status.,,
According to TTM, SOC scores designate that the intervention discrete to the stages were virtual. Although TTM model is a five-staged change plan, used to understand whether the participants are ready to cautiously regulate themselves for smoking cessation treatment, in each stage different training and counseling is required.
TTM-based intervention pretends to have an escalated effect in awareness regarding their stage of those who belong to precontemplation stage (concerning negative effects of smoking) and contemplation stage (concerning the consequences of smoking on the person and environment and its contribution toward smoking cessation). However, by the TTM intervention, those who are at the preparation stage have extended their level to manage the smoking cessation process more effortlessly and those at action and maintenance stage have sustained a better level to manipulate encouraging factors and evolved the alternative behavior and sustained that behavior. This is in agreement with the study done by Kristeller et al. who reported that there is an inflation in the process of Behavioral Change Scale mean scores among smokers by TTM-based intervention. A similar study by Grimshaw and Stanton analyzed the results of 15 studies, which consisted of behavioral model-based interventions for smoking cessation in adolescents and stated that the smoking cessation rate was 15% in developing countries. A study done by Lawendowski and Kim found a statistically significant difference between the SOC and smoking cessation program.
In this systematic review, among all included studies, a study done by Bakan B et al. additionally assessed the smoking status outcome by the Fagerstrom Test for Nicotine Dependence (FTND) scores. Compared to the HBM group, those in the TTM group were found to have reduced FTND scores after the trainings. This result highlights that the physical dependence on nicotine, which could be analog with the increase in the imminent progression through change stages which are trusted as a change in approbation of the smoking cessation evidence that smoking cessation interventions by behavioral models (especially TTM-based interventions) can reduce smoking rates among smokers.
Hence, there is a need for long-term studies for appraising the effectiveness of smoking cessation interventions based on other individual- and community-based behavioral model approaches in the future. Besides that, naught to carry out the meta-analysis for effectiveness of models on smoking cessation must be taken as a limitation of the assessed primary studies and thereby the general applicability of the evidence of the present review is limited. Similar duration of follow-up (6–12 months) and consistent outcome measures (TTM component based) in the included studies reviewed to compare the results quantitatively could be taken as the strength of this study.
| Conclusion|| |
Both HBM- and TTM-based trainings were found to have a pragmatic effect on smoking cessation as well as succession between the stages. In addition, TTM-based intervention was useful in understanding the different stages the individuals were concerning smoking cessation. This review provides the scope of deciding a pertinent treatment plan for the individual and increases success in smoking abstinence.
We would like to thank ANMs of Shahzadpur block, Haryana.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]