Ildiko Tombor

Smoker Identity and Its Potential Role in Young Adults’ Smoking Behavior: A Meta-Ethnography

Objective: Identity is an important influence on behavior. To identify potential targets for smoking cessation interventions in young adults, we synthesized findings from qualitative studies on smoker identity and potential influences on smoking and smoking cessation. Methods: A systematic search of 4 electronic databases up to September 19, 2013, was conducted to identify qualitative studies on smoker identity in smokers and ex-smokers aged 16–34. Key concepts were extracted from individual studies and synthesized into higher-order interpretations by following the principles of meta-ethnography. Results: Seventeen relevant papers were identified. At the highest level of interpretation, we identified 4 types of findings: (a) contributory factors to identity, (b) identity in relation to smoking, (c) contextual and temporal patterning, and (d) behavior in relation to smoking. Contributory factors included the desire to establish aspirational individual and social identities, enact a smoker identity appropriate to the momentary social context, and alter personal nonsmoking rules when consuming alcohol. Smoker identity was multifaceted and incorporated individuals’ defensive rationalizations, and both positive and negative feelings attached to it. Smoker identities took time to develop, were subject to change, and were context dependent. Identity was found to play a role in quit attempts. Conclusions: Qualitative research into the identity of young adult smokers has established it as a multifaceted phenomenon serving important functions but also involving conflict and defensive rationalizations. It develops over time and contextual factors influence its expression. The nature of a smoker’s identity can play an important role in smoking cessation.

Does non-smoker identity following quitting predict long-term abstinence? Evidence from a population survey in England

Aims ‘Categorical self-labels’ (e.g. thinking of oneself as a smoker or non-smoker) are important aspects of identity that can have a fundamental influence on behaviour. To explore the role identity aspects relating to smoking can play in smoking cessation and relapse, this study assessed the prospective associations between taking on a non-smoker identity following quitting and long-term abstinence. Methods A representative sample of 574 ex-smokers in England who quit smoking in the past year was followed-up at three (N = 179) and six months (N = 163). Post-quit identity relating to smoking (‘I still think of myself as a smoker’ or ‘I think of myself as a non-smoker’), and demographic and smoking-related characteristics were assessed at baseline. Self-reported smoking abstinence was assessed at follow-ups. Results Non-smoker identity was reported by 80.3% (95%CI 76.8–83.4) of recent ex-smokers. Younger age (p = 0.017) and longer abstinence (p < 0.001) were independently associated with a post-quit non-smoker identity. After adjusting for covariates, non-smoker identity (p = 0.032) and length of abstinence at baseline (p < 0.001) were associated with continued abstinence at three month follow-up, and baseline length of abstinence (p = 0.003) predicted continued abstinence at six months. Conclusions The majority of people who quit smoking recently consider themselves as non-smokers. Younger people and those who have been abstinent for longer are more likely to take on a non-smoker identity. Ex-smokers who make this mental transition following a quit attempt appear more likely to remain abstinent in the medium term than those who still think of themselves as smokers.

The effect of reducing the threshold for carbon monoxide validation of smoking abstinence - Evidence from the English Stop Smoking Services

INTRODUCTION The most commonly used threshold of expired-air carbon monoxide (CO) concentration to validate self-reported smoking abstinence is <10 parts per million (ppm). It has been proposed to reduce this threshold. This study examined what effect a reduction would have on short-term success rates in clinical practice. METHODS A total of 315,718 quit attempts supported by English NHS Stop Smoking Services were included in the analysis. The proportion of 4-week quits as determined by the Russell standard (<10ppm) that also met lower thresholds was calculated for each unit change from <9ppm to <2ppm. Additionally, associations of established predictors with outcome were assessed in logistic regressions for selected thresholds. RESULTS At <10ppm, 35% of quit attempts were regarded as successful. Differences for a single unit reduction increased with each reduction; small reductions had very little impact (e.g. <8ppm: 34.7% success), but at <3ppm, only 26.3% would still be regarded as successful. With the threshold reduced to <3ppm established predictors of cessation showed a weaker association with outcome than with the threshold at <10ppm suggesting an increase in error of outcome measurement. CONCLUSIONS Reducing the threshold for expired-air CO concentration to validate abstinence would have a minimal effect on success rates unless the threshold were reduced substantially which would likely increase error of measurement.

Pilot randomized controlled trial of an internet-based smoking cessation intervention for pregnant smokers ('MumsQuit')

Background Internet-based Smoking Cessation Interventions could help pregnant women quit smoking, especially those who do not wish to, or cannot, access face-to-face or telephone support. This study aimed to preliminarily evaluate the effectiveness and usage of a fully automated smoking cessation website targeted to pregnancy, ‘MumsQuit’, and obtain an initial effect-size estimate for a full scale trial. Methods We recruited 200 UK-based pregnant adult smokers online to a two-arm double-blind pilot RCT assessing the effectiveness of MumsQuit compared with an information-only website. MumsQuit was adapted from a generic internet smoking cessation intervention, ‘StopAdvisor’. The primary outcome was self-reported continuous 4-week abstinence assessed at 8 weeks post-baseline. Secondary outcomes were automatically collected data on intervention usage. Results Participants smoked 15 cigarettes per day on average, 73% were in the first trimester of their pregnancy, 48% were from lower socioeconomic backgrounds, and 43% had never used evidence-based cessation support. The point estimate of odds ratio for the primary outcome was 1.5 (95% CI = 0.8–2.9; 28% vs. 21%). Compared with control participants, those in the MumsQuit group logged in more often (3.5 vs. 1.3, p < 0.001), viewed more pages (67.4 vs. 5.7, p < 0.001) and spent more time browsing the website (21.3 min vs. 1.0 min, p < 0.001). Conclusions MumsQuit is an engaging and potentially helpful form of support for pregnant women who seek cessation support online, and merits further development and evaluation in a full-scale RCT.

Development of SmokeFree Baby: a smoking cessation smartphone app for pregnant smokers.

Pregnant smokers may benefit from digital smoking cessation interventions, but few have been designed for this population. The aim was to transparently report the development of a smartphone app designed to aid smoking cessation during pregnancy. The development of a smartphone app (‘SmokeFree Baby’) to help pregnant women stop smoking was guided by frameworks for developing complex interventions, including the Medical Research Council (MRC), Multiphase Optimization Strategy (MOST) and Behaviour Change Wheel (BCW). Two integrative behaviour change theories provided the theoretical base. Evidence from the scientific literature and behaviour change techniques (BCTs) from the BCT Taxonomy v1 informed the intervention content. The app was developed around five core modules, each with a distinct intervention target (identity change, stress management, health information, promoting use of face-to-face support and behavioural substitution) and available in a ‘control’ or ‘full’ version. SmokeFree Baby has been developed as part of a multiphase intervention optimization to identify the optimum combination of intervention components to include in smartphone apps to help pregnant smokers stop smoking.

The needs and preferences of pregnant smokers regarding tailored Internet-based smoking cessation interventions: a qualitative interview study

BackgroundInternet-based Smoking Cessation Interventions (ISCIs) may help pregnant smokers who are unable, or unwilling, to access face-to-face stop smoking support. Targeting ISCIs to specific groups of smokers could increase their uptake and effectiveness. The current study explored the needs and preferences of pregnant women seeking online stop smoking support with an aim to identify features and components of ISCIs that might be most attractive to this population.MethodsWe conducted qualitative interviews with thirteen pregnant women who completed the intervention arm of a pilot randomized controlled trial of a novel ISCI for pregnant smokers (‘MumsQuit’). The interviews explored women’s views towards MumsQuit and online support with quitting smoking in general, as well as their suggestions for how ISCIs could be best targeted to pregnancy. Interview transcripts were analyzed using Framework Analysis.ResultsParticipants expressed preferences for an accessible, highly engaging and targeted to pregnancy smoking cessation website, tailored to individuals’ circumstances as well as use of cessation medication, offering comprehensive and novel information on smoking and quitting smoking in pregnancy, ongoing support with cravings management, as well as additional support following relapse to smoking. Participants also viewed as important targeting of the feedback and progress reports to baby’s health and development, offering personal support from experts, and providing a discussion forum allowing for communication with other pregnant women wanting to quit .ConclusionsThe present study has identified a number of potential building blocks for ISCIs targeted to quitting smoking in pregnancy. Pregnant smokers willing to try using ISCI may particularly value an engaging intervention offering a high degree of targeting of comprehensive information to them as a group and tailoring support and advice to their individual needs, as well as one providing post-relapse support, peer-to-peer communication and personal support from experts.

Measures of fidelity of delivery of, and engagement with, complex, face-to-face health behaviour change interventions: A systematic review of measure quality

Purpose Understanding the effectiveness of complex, face‐to‐face health behaviour change interventions requires high‐quality measures to assess fidelity of delivery and engagement. This systematic review aimed to (1) identify the types of measures used to monitor fidelity of delivery of, and engagement with, complex, face‐to‐face health behaviour change interventions and (2) describe the reporting of psychometric and implementation qualities. Methods Electronic databases were searched, systematic reviews and reference lists were hand‐searched, and 21 experts were contacted to identify articles. Studies that quantitatively measured fidelity of delivery of, and/or engagement with, a complex, face‐to‐face health behaviour change intervention for adults were included. Data on interventions, measures, and psychometric and implementation qualities were extracted and synthesized using narrative analysis. Results Sixty‐six studies were included: 24 measured both fidelity of delivery and engagement, 20 measured fidelity of delivery, and 22 measured engagement. Measures of fidelity of delivery included observation (n = 17; 38.6%), self‐report (n = 15; 34%), quantitatively rated qualitative interviews (n = 1; 2.3%), or multiple measures (n = 11; 25%). Measures of engagement included self‐report (n = 18; 39.1%), intervention records (n = 11; 24%), or multiple measures (n = 17; 37%). Fifty‐one studies (77%) reported at least one psychometric or implementation quality; 49 studies (74.2%) reported at least one psychometric quality, and 17 studies (25.8%) reported at least one implementation quality. Conclusion Fewer than half of the reviewed studies measured both fidelity of delivery of, and engagement with complex, face‐to‐face health behaviour change interventions. More studies reported psychometric qualities than implementation qualities. Interpretation of intervention outcomes from fidelity of delivery and engagement measurements may be limited due to a lack of reporting of psychometric and implementation qualities. Statement of contribution What is already known on this subject? Evidence of fidelity and engagement is needed to understand effectiveness of complex interventions Evidence of fidelity and engagement are rarely reported High‐quality measures are needed to measure fidelity and engagement What does this study add? Evidence that indicators of quality of measures are reported in some studies Evidence that psychometric qualities are reported more frequently than implementation qualities A recommendation for intervention evaluations to report indicators of quality of fidelity and engagement measures

Usability testing of a smoking cessation smartphone application ('SmokeFree Baby'): a think-aloud study with pregnant smokers

Background Only a few digital interventions have been developed for pregnant smokers, and little is known about the acceptability and usability of smartphone apps to aid cessation in pregnancy. This study aimed to explore pregnant smokers’ views on the design, content and usability of a pregnancy-specific smoking cessation app in order to inform intervention development and optimisation. Methods Ten interviews were conducted and the ‘think-aloud’ protocol was used in order to explore participants’ views about a smoking cessation smartphone app (‘SmokeFree Baby’). The data were subsequently thematically analysed. Participants were 18 and over, pregnant, and daily or weekly cigarette smokers. Results Three main themes were identified: views about the design elements, mode of delivery and content of the intervention. App design was considered as an important element that might influence potential users’ engagement with the intervention. Participants felt that the intervention content was educational, motivational and non-judgemental. However, it was emphasised that the app should provide further options for personalisation and include more practical features. Conclusions Delivering smoking cessation support via a smartphone app can be feasible and acceptable for pregnant smokers. They appear to value content that is motivational, educational and personalised, and meeting these requirements may be important for user experience and promoting engagement with the intervention.

Progression towards smoking cessation: qualitative analysis of successful, unsuccessful and never quitters

ABSTRACT Background: Understanding how people transition between phases of not making a quit attempt to stopping smoking successfully is important in order to optimize interventions. This study aimed to explore differences in attitudes towards smoking and quitting among smokers and ex-smokers. Methods: Adult (age 18 and over) successful (n = 8), unsuccessful (n = 8) and never quitters (n = 7) were recruited through stop-smoking services in England. Semi-structured interviews were conducted and data were analysed using framework analysis. Results: Seven themes (starting to smoke, positive appraisal of smoking, responsibility for past/current smoking, negative effects of smoking, reasons to quit, process of quitting, and identity) were identified in all groups. Sub-group differences were explored and used to derive six typologies with descriptive characteristics: committed smokers, aware smokers, forced attempters, struggling attempters, pragmatic ex-smokers, and committed non-smokers. Using these typologies and the smallest number of differentiating factors between them (awareness of negative effects, motivation to stop and acceptance of responsibility), a parsimonious model of progression towards smoking cessation was developed. Conclusions: Awareness of negative effects, motivation and, crucially, a sense of commitment for taking responsibility to take actions towards behavior change may be important for whether smokers attempt to quit and progress to a successful quit attempt.

Are digital interventions for smoking cessation in pregnancy effective? A systematic review protocol.

BackgroundBehavioural support for smoking cessation in pregnancy can be effective; however, many pregnant women face barriers to seeking support to stop smoking. Some digital interventions have been found to be effective for smoking cessation in the general population and may be effective for supporting cessation in pregnancy due to their flexibility and the potential for personalisation. To date, there is limited evidence of the effectiveness of digital interventions for smoking cessation in pregnancy. This review aims to assess the following: (1) whether digital interventions are effective at promoting smoking cessation among pregnant women; (2) which behaviour change techniques (BCTs) or combinations of BCTs are associated with the effectiveness of digital interventions for smoking cessation in pregnancy; and (3) whether the number of BCTs used is associated with the effectiveness of digital interventions for smoking cessation in pregnancy.MethodsThis review will include digital interventions delivered largely through computer (PC or laptop), video/DVD, mobile phone (including smartphones) or portable handheld device (e.g. tablet, iPad) and include websites, mobile or tablet applications and SMS text messages. Interventions must be randomised or quasi-randomised controlled trials aimed at women who smoke in pregnancy, with smoking cessation as a measured outcome (preferably the latest available point prevalence smoking status measure taken during pregnancy, biochemically verified if available). Electronic bibliographic databases will be searched to identify suitable studies indexed in the following: Academic Search Complete, ASSIA, CINAHL, The Cochrane Library, EMBASE, Medline, PsycINFO, Scopus, and Web of Science. The search strategy will include key words and database-specific subject headings relating to ‘pregnancy’ and ‘smoking’ and synonyms for the terms ‘digital’ and ‘randomised controlled trial’. Where required and where possible, the first and second authors will independently code interventions and control groups for BCTs. If data allows, meta-analyses will be used to assess intervention effectiveness and the effectiveness of BCTs.DiscussionThis systematic review will provide a detailed synthesis of the effectiveness of current research using digital interventions for smoking cessation in pregnancy, to build on the evidence base and guide the development of future research in this area.Systematic review registrationPROSPERO CRD42016036201