Effectiveness of tobacco cessation counselling and behavioural changes Using Multi Theory Model (MTM): A follow-up study

Vijay Kumar; Bhavna Sabbarwal; Amrita Jaggi; Pratibha Taneja

doi:10.4103/ijdr.IJDR_904_19

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ORIGINAL RESEARCH

Year : 2021 | Volume : 32 | Issue : 1 | Page : 56-60

Effectiveness of tobacco cessation counselling and behavioural changes Using Multi Theory Model (MTM): A follow-up study

Vijay Kumar¹, Bhavna Sabbarwal², Amrita Jaggi², Pratibha Taneja³
¹ Senior Medical Reviewer, IQVIA, Bengaluru, Karnataka, India
² Department of Public Health Dentistry, Faculty of Dental Sciences, SGTU, Gurugram, Haryana, India
³ Department of Public Health Dentistry, Sudha Rustagi Dental College, Faridabad, Haryana, India

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Date of Submission	04-Dec-2019
Date of Decision	02-May-2020
Date of Acceptance	22-Nov-2020
Date of Web Publication	13-Jul-2021

Abstract

Background: Effective tobacco cessation programs using advice and counselling, have helped a substantial proportion of people quit smoking. Effectiveness of this tobacco cessation counselling needs to be evaluated. Aim: The aim of the present study was to evaluate the effectiveness of tobacco cessation counselling and behavioural changes using Multi Theory Model (MTM). Setting and Design: A non-randomised uncontrolled trial was conducted on 100 tobacco users visiting dental college in Bangalore. Methods and Materials: A 28 item questionnaire multi-theory model (MTM) for health behaviour was administered at baseline, 2 weeks, 6 weeks and 12 weeks after providing standardized tobacco cessation counselling (TCC) intervention at baseline. Statistical Analysis: Data were analysed and comparison were made using repeated measure ANOVA and Bonferroni adjustment (p < 0.05). Results: A total of 64 participants completed the 12 week follow-up. The mean age was 44.3 ± 10.1 years and 75.8% were males. There was significantly increase in mean MTM behaviour change score from baseline (32.78 ± 4.8) to 2 weeks (52.37 ± 5.27), 6 weeks (49.81 ± 4.34) and 12 weeks (48.7 ± 3.50) (p < 0.001). Conclusion: There was increase in MTM model scores in subsequent follow up suggesting behavioural changes and overall effectiveness of the Tobacco cessation counselling (TCC) among tobacco users.

Keywords: Behaviour modification, multi-theory model, tobacco cessation, tobacco use

How to cite this article:
Kumar V, Sabbarwal B, Jaggi A, Taneja P. Effectiveness of tobacco cessation counselling and behavioural changes Using Multi Theory Model (MTM): A follow-up study. Indian J Dent Res 2021;32:56-60

How to cite this URL:
Kumar V, Sabbarwal B, Jaggi A, Taneja P. Effectiveness of tobacco cessation counselling and behavioural changes Using Multi Theory Model (MTM): A follow-up study. Indian J Dent Res [serial online] 2021 [cited 2023 Jun 1];32:56-60. Available from: https://www.ijdr.in/text.asp?2021/32/1/56/321390

Introduction

Tobacco use is the leading cause of preventable oral and systemic disease, disability and morality globally. According to the World Health Organization (WHO), 21% of the total world population above 15 years smoked tobacco in 2012. Currently, approximately 5.4 million people die each year due to tobacco-related disease, with 2.41 million deaths in the developing and 2.43 million in the developed countries.^[1] This figure expected to increase up to more than 8 million a year by 2030. In 2010, the Centres for Disease Control and Prevention (CDC) reported that 68.8% of adult tobacco users wanted to stop tobacco use and 52.4% had made a quit attempt but only 6.2% had been successful in quitting.^[2]

In India, the prevalence of tobacco use reduced from 38.6% to 28.6%.^[3] This reduction in prevalence might be due to education regarding adverse effects of tobacco use, legal and taxation system on tobacco products. Behaviour modification among tobacco users determines the cessation of habit.

Health education programs using advice and counselling, whether minimal or more intensive have helped a substantial proportion of people quit smoking.^[4] Tobacco cessation is one of the most cost-effective interventions and primary prevention modality for reducing morbidity and mortality among tobacco users due to various type of cancers. Although minimal brief interventions are proven to increase cessation rates, quit rates are often further increased by intensified level of support (length and/or number of sessions) and/or concurrent use of pharmacological aids.^[5]

The success of counselling and advice increases with the intensity of the program and may be improved by increasing the frequency and duration of contact. Several theories or models like Social Cognition Model, Health Belief Model, Self-efficacy Theory, Reasoned Action and Planned Behaviour theory have proposed for health behaviour changes. One of the theories that has guided such counselling efforts is the trans-theoretical model.^[5] The trans-theoretical model or, sometimes also called as, the stages of change model proposes that smokers move through a series of discrete stages before they quit successfully namely pre-contemplation to maintenance.^[5],[6]

However, behaviour change is complex and continuous phenomenon. There are continuing progressive and regressive changes throughout the procedure till desire outcome achieved. Based on this, continuous or non-staged models would be more appropriate for the assessment of behaviour change. Multi-theory model (MTM) suggested as the non-stage model because health behaviour change of tobacco users after the certain interventions applied over the time and behaviour modification would not described on the basis of stages of discrete changes. A meta-analysis concluded that stage-based counselling programs were neither more nor less effective than their non-stage based equivalents.^[7]

Multi-theory model theory dissects health behaviour change into two components: initiation of the behaviour change and sustenance or continuation of the health behaviour change. In the context of tobacco cessation initiation would entail starting with the decision to quit tobacco and sustenance would necessitate attaining abstinence. This theory proposes that constructs can predict the initiation and sustenance of behaviour modification. Previous study recommended a protocol that was intended to evaluate the effectiveness of tobacco cessation with MTM model and guide the counselling efforts in more robust way to get desired behaviour changes in tobacco users.^[8]

Most of the earlier studies have used stage based counselling and none of the studies have used MTM model to assess behaviour change among tobacco users.^{[9],[10],[11]}

So, the present study was conducted under following objectives: (1) To assess baseline construct data of Multi-Theory Model (MTM) before tobacco cessation counselling among tobacco users. (2) To assess and compare the construct data of Multi-Theory Model (MTM) after tobacco cessation counselling among tobacco users from baseline to 2 weeks, 6 weeks and 12 weeks.

Materials and Methods

A non-randomised uncontrolled trial design was conducted during April- October 2017 in a dental college in Bangalore city, India. After brief communication participants provided a signed informed consent, and the study was given ethical approval from the Institutional Ethical Committee, Bangalore.

A consecutive sample of hundred tobacco users (both smoking and smokeless) aged 18 years and above, who visited or referred to the Department of Public Health Dentistry were recruited for the study. Tobacco users who had cognitive impairment or other non-tobacco adverse habits, like alcohol, cannabis, drug users were excluded.

With reference to the protocol G*Power was used to calculate sample size.^[7] With statistical power of 0.80, alpha = 0.05 and 0.30 (medium) effect size for multiple comparison, a minimum of 89 participants were required. Considering dropouts, 11 more subjects were added with final sample size 100. In a structured proforma, sociodemographic details were recorded and level of addiction was determined through Fagerstrom score^[12] at baseline before intervention.

A powerpoint presentation was developed and content validation was done with the help of experts in the Public Health Dentistry. Topics for the education on tobacco and oral cancers were based on the published material by WHO.^[13]

Five topics were outlined: (I) Tobacco types and effects, (II) Tobacco related habit, (III) Benefits of stopping tobacco (IV) Self-examination for signs of oral cancers and precancerous conditions and (V) Primary prevention procedures including screening.

Each participant was given standardised 10-minute intervention with power point presentation and face to face interview. Doubt clearing sessions for participants was done separately on the same day. Therapeutic measures like oral prophylaxis, restorations and referral for speciality treatment were administered as needed. Multi theory model, a 28 items questionnaire [Supplement 1] with 6 point Likert scale was used for assessment of change in behaviour at baseline before intervention. The participants were recalled at 2 weeks. 6 weeks and 12 weeks and assessment of their tobacco habit and change in behaviour were done through same questionnaire followed by brief counselling on tobacco cessation.

Multi theory model for behaviour change divides behaviour change into two components: initiation and sustenance. There are three constructs for initiation of behaviour change: (1) participatory dialogue (2) behavioural confidence, which is the futuristic confidence in one's ability to perform and (3) changes in physical environment such as access, availability and obtainability of resources that tangibly help with behaviour change.^[7]

For sustenance of behaviour change, three constructs have been proposed: (1) emotional transformation, which is the ability to convert feelings into goals for behaviour change; (2) practice for change, which includes creating social support that helps with behaviour change.^[7]

Each question was scored on a 6-point Likert scale, which recorded how a tobacco users have experienced the change in the behaviour from 0 = most negative to 5 = most positive response. Higher scores indicated positive behaviour changes. Mean scores for initiation of behaviour change and sustenance of behaviour were calculated and subjected for the analysis.

Data were entered into Excel v13, Microsoft Corporation, Redmond, WA, USA) spreadsheets and Statistical software (SPSS version 22.0; SPSS, Chicago, IL, USA) was used. Participants completed minimum two follow up were considered in the analysis. Dropout analysis with hot-deck imputation of data was done for participants with loss of follow up. Repeated measure ANOVA used to find the mean score difference of behaviour changes in from baseline to 12 weeks. Multiple comparison was done with Bonferroni adjustment. Scores per question were calculated for each construct of the behaviour initiation and behaviour sustenance. Independent t test was used to find mean difference between initiation and sustenance. Level of addiction was determined by Fagerstrom scores, which was divided into <6-low level of addiction and ≥6- high level of addiction. Two way ANOVA used to find out significant difference in level of addiction and behaviour change among participants. A p < 0.05 was considered as significant.

Results

Among 100 tobacco users, 64 have completed all the follow-ups from baseline to 12 weeks. A total of 12 participants further completed at least 2 follow-ups. After hot deck, total sample of 88 tobacco users were subjected to analysis. Participants flow diagram described in [Figure 1].

Figure 1: Study participant flow diagram

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In the present study, the age of the participants ranged from 29 to 63 years with mean age 44.39 ± 10.1 years. Among 88 tobacco users, 60 were males and 28 were females [Table 1].

Table 1: Baseline charactertics of the participants

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There was significant increase in mean score of behaviour change of MTM model from baseline to 2, 6 and 12 weeks. (p < 0.001) Multiple comparison have shown significant difference from baseline to 2 weeks (p < 0.001), baseline to 6 weeks (p = 0.002), baseline to 12 weeks (p = 0.04) and 2 weeks to 6 weeks (p = 0.007). However, there was no significant difference in behaviour change between 6 weeks to 12 weeks (p = 0.96). On the basis of level of addiction among tobacco users, there was significant difference in behaviour changes in low and high level of addiction of tobacco at 2 weeks (p = 0.03) and 6 weeks (p = 0.02). However, no significant difference was found at 12 weeks follow-up. (p = 0.12). The mean construct scores of behaviour initiation was significantly higher than behaviour sustenance scores among participants at baseline (p = 0.016), 2 weeks (p = 0.02) and 6 weeks (p = 0.03). However, difference was not found at 12 weeks [Table 2].

Table 2: Mean MTM scores difference between baselines to 2 weeks, 6 weeks and 12 weeks among study participants in relation to level of addiction and construct score

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Discussion

Tobacco cessation counselling efforts made imperative changes in the behaviour of the tobacco users. In the present study, majority were males and smokers, which was in the line of the tobacco users globally. Age range was 29–63 years old which was comparable to the age of tobacco users globally and nationally.^[3]

Programs for quitting smoking have played a significant role in reduction of smoking in the globally. Interventions like counselling, NRT and pharmacotherapy for tobacco cessation is based on the stage of the tobacco users came for the cessation. In counselling various methods are popular that include telephone counselling, interactive computer programs, training of health care providers such as physicians or pharmacists and counselling by lay health volunteers.^[14]

There is consistent evidence that individual counselling, used independently of pharmacotherapy, was estimated to increase cessation by 40%–80% after at least six months using staged models.^[15] On the other hand, behaviour change may be consider as a continuum categorization like staged models may not capture subtle behavioural change. This is best achieved using non staged models. This study used MTM model (non- staged) to find behavioural changes for the period of 12 weeks.

In the present study, participants were given individual counselling and there was no group interventions. Each participant was given standardized time and he or she were allowed to clear their doubts in 'doubt clearing sessions'. This helped them to understand and communicate better and able to come out from inherent and social stigma.

Studies have demonstrated empirical evidence supporting predictive ability of MTM with several health behaviours such as physical activity, small portion size consumption, and adequate sleep.^[16],[17] However, this is the first study performed on tobacco users.

Assessment of the behaviour change is imperative part of tobacco cessation. In the present study, there was significant increase in mean MTM score of behaviour change from baseline to subsequent follow-ups. This suggests the effect of tobacco cessation counselling on the behaviour change among tobacco users. However, mean difference was highest from baseline to 2 weeks (mean difference = 18.93) followed by baseline to 6 weeks (mean difference = 16.51) and baseline to 12 weeks (mean difference = 15.48). Tobacco dependence is best viewed as a chronic disease with remission and relapse. Even though both minimal and intensive interventions increase smoking cessation, most people who quit smoking with the aid of such interventions will eventually relapse and may require repeated attempts before achieving long-term abstinence. Moreover, there is little understanding of how such treatments produce their therapeutic effects.

Standardised tobacco cessation counselling was given at baseline and brief counselling was given during follow up visits. Maximum difference from baseline to 2 weeks followed by baseline to 6 and baseline to 12 weeks. The effect till 12 weeks might vary and justified with the lower mean MTM score than earlier follow-ups.

One of the vital elements which affects the behaviour modification is the level of addiction. Level of addiction was measured through Fagerstrom Test for Nicotine Dependence. There was no significant difference in mean behaviour MTM scores between participants with high level and low level of addiction at baseline. However, participants with higher level of addiction had lesser mean behaviour change score compared to participants with low level of addiction at 2^nd and 6^th weeks of follow ups. Higher the dependence, lower the tobacco users were motivated for the quitting and less changes in their behaviour. Level of addition acted as a barrier for change in behaviour in this study. There was no significant difference in mean MTM model score after 12 weeks, suggested for long term use this model with counselling overcome the effect of addition level in behaviour modification.

This differentiation of initiation of the behaviour change and sustenance or continuation of the health behaviour change was needed because the constructs that influence initiation of change are different than the constructs that sustain the behaviour change.

In the context of tobacco cessation, behaviour initiation would entail starting with the decision to quit tobacco. The first construct for initiation is participatory dialogue. This has derived from the Freire's model of adult education. Participatory dialogue is also present in the other models like trans theoretical model or health belief models, but majority contribution in dialogue is from health care professionals or facilitators. Uniqueness of MTM model is two way communications between the tobacco users and cessation counselling providers.

Second construct for behaviour initiation of tobacco cessation is behavioural confidence, which was derived from Bandura's self-efficacy and Ajzen's perceived behavioural control. This construct evaluates the patient's confidence for behaviour modification and able to come out the withdrawal symptoms. This includes able to quit tobacco this week, able to do the task without being anxious and relax despite quitting.

Third construct for behaviour initiation of tobacco cessation is change in physical environment of tobacco users. This construct evaluates if tobacco users can get rid of all tobacco products by not purchasing and ability to spend time without tobacco. It motivates tobacco users to keep environment tobacco free and also be influential in others life.

In order to sustain the behaviour, change of continuing to abstain from tobacco the first construct that is important is emotional transformation derived from the emotional intelligence theory. The second construct for sustenance of being abstinent is practice for change derived from Freire's adult education model's praxis which refers to active reflection and reflective action such as asking the participants to maintain a diary or a journal or in this age of technology by using apps. The final construct for sustenance of quitting smoking is the social environment derived from construct of environment, social support getting help from family member, friends, or health care professionals.

In the present study, the mean score of change in the construct of behaviour initiation was significantly higher than construct of the behaviour sustenance from baseline to 6 weeks. In early follow-up till 6 weeks, behaviour initiation construct had major contribution in the behavioural changes in the tobacco users. This is mostly influenced by counselling efforts like communication, building their confidence and stop purchasing the tobacco products. However, follow-up at 12 weeks failed to show significant difference, and similar contributions were found from both the initiation and sustenance construct. This might be due to change in their emotional state towards tobacco products. Initiated behaviour for cessation of tobacco would be sustained with the help of family support and self-monitoring.

Strength and limitation

This was the first study to determine effectiveness of TCC using a non-stage MTM theory model. Though dropouts were present in the subsequent follow ups, Imputation analysis was done to minimize the bias due to dropouts. Non-randomised trial without control was one of the important limitation of the study. Inherent biases of questionnaire study was present. Randomized control trials will be needed to evaluate the effectiveness of MTM model as guiding principle in tobacco cessation.

Conclusion

There was significant increase in MTM scores after tobacco cessation counselling, from base line to 2, 6 and 12 weeks, suggestive of effectiveness of counselling on the behaviour changes. Addiction limits change in behaviour at follow-ups. Behaviour initiation construct contributed most of the behaviour changes till 6 weeks.

There is need to assess the behavioural change in every 6 weeks, with monitoring of the initiation and sustenance constructs scores. Use of tobacco products, clinical examination and biochemical analysis should be done, which will further support the assessment of behaviour modification.

Acknowledgements

We would like to acknowledge all the study participants and authorities of dental college, Bangalore for permissions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Supplement 1: Instrument for Measuring Change in Smoking

Directions: This survey is voluntary, which means you may choose not to complete it or not to answer individual questions. There is no direct benefit of this survey to you. All data from this survey will be anonymous and kept secret. Your responses will help in developing effective smoking cessation programs. Please put an X mark by the response or fill the response that correctly describes your position. Thank you for your help!

During the past seven days, did you smoke one or more cigarettes?

What is your gender?

How old are you today? _______ years

What is your race/ethnicity?

What is your education?

Do you work?

What is your yearly household income?

How long have you smoked? _____________ (in years)

How many cigarettes a day do you smoke? ________

… be healthy.

…save money.

… get sick less often.

…smell better.

… enjoy life more.

… not be able to relax as well.

… not be able to socialize as well.

… miss it.

… not be able to overcome the urge.

… lose friends.

… this week?

… this week and complete all work related tasks?

… this week and relax?

… this week without getting anxious?

… this week without getting withdrawal symptoms?

… be able to get rid of all cigarettes from your environment this week?

… not buy any cigarettes this week?

… be able to substitute smoking time with something else this week?

… direct your emotions/feelings to the goal of being smoke free every week?

… motivate yourself to be smoke free every week?

… overcome self doubt in accomplishing the goal of being smoke free every week?

… keep a self diary to monitor your smoking urge every week?

… be smoke free every week if you encounter barriers?

… change your plan for being smoke free every week if you face difficulties?

…family member to be smoke free every week?

…friend to be smoke free every week?

…health professional to be smoke free every week?

…quit smoking in the upcoming weeks.

… smoke free every week from now on.     

………………………………………………………………………………………………………

Thank you for your time!

Scoring

Construct of advantages: Scale: Never (0), Hardly ever (1), Sometimes (2), Almost always (3), Always (4). Summative score of Items 10-14. Possible range: 0- 20. High score associated with likelihood of initiation of behaviour change.

Construct of disadvantages: Scale: Never (0), Hardly ever (1), Sometimes (2), Almost always (3), Always (4). Summative score of Items 15-19. Possible range: 0- 20. Low score associated with likelihood of initiation of behaviour change.

Subtract the score of disadvantages from advantages to come with a score for participatory dialogue.

Construct of behavioural confidence: Scale: Not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4). Summative score of Items 20-24. Possible range 0- 20. High score associated with likelihood of initiation of behaviour change.

Construct of changes in physical environment: Scale: Not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4). Summative score of Items 25-27. Possible range 0-12. High score associated with likelihood of initiation of behaviour change.

Construct of emotional transformation: Scale: Not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4). Summative score of Items 28-30. Possible range 0- 12. High score associated with likelihood of sustenance of behaviour change.

Construct of practice for change: Scale: Not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4). Summative score of Items 31-33. Possible range 0-12. High score associated with likelihood of sustenance of behaviour change.

Construct of changes in social environment: Scale: Not at all sure (0), slightly sure (1), moderately sure (2), very sure (3), completely sure (4). Summative score of Items 34-36. Possible range 0-12. High score associated with likelihood of sustenance of behaviour change.

For modelling initiation dependent variable can be Item 37: not at all likely (0), somewhat likely (1), moderately likely (2), very likely (3), and completely likely (4) and multiple regression can be used. For modelling sustenance dependent variable can be Item 38: not at all likely (0), somewhat likely (1), moderately likely (2), very likely (3), and completely likely (4) and multiple regression can be used.

References

1.	World Health Organization (WHO). Global Health Observatory (GHO) data: Prevalence of tobacco use, 2016. Available from: http://www.who.int/gho/tobacco/use/en/. [Last accessed on 2017 Nov 27].
2.	Centers for Disease Control and Prevention (CDC). Quitting smoking among adults-United States, 2001-2010. MMWR Morb Mortal Wkly Rep 2011;60:1513-9.
3.	Global adult tobacco survey (GATS-2) India. 2016-17. Ministry of Health and Family Welfare, Government of India, New Delhi.
4.	Reducing Tobacco Use: A Report of the Surgeon General. Available from: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr4916a1.htm. [Last accessed on 2017 Nov 27].
5.	Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12:38-48.
6.	Glanz K, Barbara K, Rimer BK, Viswanath K. Health Behavior and Health Education Theory, Research, and Practice. 4^th ed. John Wiley & Sons, Inc.; 2008.
7.	Cahill K, Lancaster T, Green N. Stage-based interventions for smoking cessation. Cochrane Database Syst Rev2010;10:CD004492. doi: 10.1002/14651858.CD004492.pub4.
8.	Sharma M, Khubchandani J, Nahar VK. Applying a new theory to smoking cessation: Case of multi-theory model (MTM) for health behavior change. Health Promot Perspect 2017;7:102-5.
9.	Robinson LM, Vail SR. An integrative review of adolescent smoking cessation using the transtheoretical model of change. J Pediatr Health Care 2012;26:336-45.
10.	Koyun A, Eroğlu K. The effect of transtheoretical model-based individual counseling, training, and a 6-month follow-up on smoking cessation in adult women: A randomized controlled trial. Turk J Med Sci 2016;46:105-11.
11.	Aveyard P, Massey L, Parsons A, Manaseki S, Griffin C. The effect of transtheoretical model based interventions on smoking cessation. Soc Sci Med 2009;68:397-403.
12.	Heatherton TF, Kozlowski LT, Frecker RC, Fagerstrom KO. The Fagerström test for nicotine dependence: A revision of the Fagerstrom Tolerance Questionnaire. Br J Addict 1991;86:1119-27.
13.	Toolkit for oral health professionals to deliver brief tobacco interventions in primary care. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.
14.	Nayan S, Gupta MK, Strychowsky JE, Sommer DD. Smoking cessation interventions and cessation rates in the oncology population: An updated systematic review and metaanalysis. Otolaryngol Head Neck Surg 2013;149:200-11.
15.	Lancaster T, Stead LF. Individual behavioural counselling for smoking cessation. Cochrane Database Syst Rev 2017;3:CD001292. doi: 10.1002/14651858.CD001292.pub3.
16.	Sharma M, Catalano HP, Nahar VK, Lingam VC, Johnson P, Ford MA. Applying Multi-Theory Model (MTM) of health behavior change to predict water consumption instead of sugar-sweetened beverages. J Res Health Sci 2017;17:e00370.
17.	Sharma M, Catalano HP, Nahar KV, Lingam V, Johnson P, Ford MA. Using multi-theory model to predict initiation and sustenance of small portion size consumption among college students. Health Promot Perspect 2016;6:137-44.

Correspondence Address:
Dr. Vijay Kumar
IQVIA, Bengaluru, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijdr.IJDR_904_19

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