Review ArticleCharacteristics and impact of theory of planned behavior interventions on smoking behavior: A systematic review of the literature
Introduction
Despite years of progress supported by the World Health Organization (WHO) Framework Convention on Tobacco Control to guide national policies, 19% of the world population is currently smoking, causing 8 million deaths every year (World Health Organization, 2019). In order to prevent tobacco smoking, many countries are supporting actions of tobacco control for a long time, with nonetheless a high variability in the effectiveness of the implemented interventions (e.g., Rice et al., 2017). Applying theory to design and evaluate behavior change interventions is currently viewed as good practice (Conner and Norman, 2015). As highlighted by some authors (Michie and Prestwich, 2010), implementing theory-based interventions provides several benefits, including the identification of key constructs to target and the selection of appropriate intervention techniques to use. Moreover, collecting empirical data from theory-based interventions can also aid in the understanding of the underlying mechanisms (proposed by the theory) implied in the effectiveness of interventions (Michie et al., 2018). In this context, using theory to design interventions is advocated to contribute to the development of potentially efficient and replicable programs, to aid in the understanding of mechanisms of behavior change, and to provide a basis for theorists to refine their models (Rothman, 2004).
To design interventions, many theories of behavior change are available (Michie et al., 2014). One popular model that has received wide attention in health behavior research is the theory of planned behavior (TPB) (Ajzen, 1991). The TPB is a model of rational decision-making that proposes that behavior is determined by a number of potentially changeable cognitions. More precisely, the model proposes that behavioral intention (i.e., an individual's motivation to act) is the immediate antecedent of behavior. Intention, in turn, is determined by attitude (i.e., favorable or unfavorable evaluation of the targeted behavior), subjective norm (i.e., perceived social pressure from important others about performing the behavior and level of adoption of the behavior by important others) and perceived behavioral control (PBC) (i.e., perceived ability to perform the behavior). This latter construct is also hypothesized to directly predict behavior. Numerous reviews and meta-analyses have reported the validity of the TPB to explain various health behaviors such as physical activity, dietary behavior, or alcohol consumption (Cooke et al., 2016; Hagger et al., 2016; McDermott et al., 2015; McEachan et al., 2011). Concerning smoking behavior, if studies could vary with regard to the behavioral outcome (e.g., smoking reduction, smoking cessation) or the kind of products explored (e.g., cigarettes only, drugs including tobacco), previous meta-analyses and reviews have also reported the validity of the TPB in those different contexts (McEachan et al., 2011; Topa and Moriano, 2010).
Otherwise, the TPB has also been used as a theoretical framework for designing health behavior interventions. Previous reviews and meta-analyses have reported that TPB-based interventions appear efficient in various behavioral domains, including the reduction of sexual risk behaviors (Tyson et al., 2014), or the promotion of physical activity (Gourlan et al., 2016). However, information concerning the efficacy of TPB-based interventions specifically in the domain of smoking behavior remains sparse. Hardeman et al. (2002) systematically reviewed the application of the TPB in behavior change interventions. They noted that at this time only two papers out of 30 addressed smoking behavior and that those papers did not examine the impact of TPB-based interventions on smoking behavior per se but solely evaluated the interest of subjects to participate in a program of smoking cessation. More recently, Steinmetz et al. (2016) reported in their meta-analysis a significant global effect of TPB-based interventions to promote change in various health behaviors and change in TPB variables. However, interventions targeting smoking behavior were regrouped within “alcohol and drugs” studies, which preclude the possibility of establishing a detailed synthesis of TPB-based interventions specifically in the smoking domain.
The present systematic review aims to identify and synthesize knowledge concerning the efficacy of TPB-based interventions on smoking behavior of minors or adults in studies using quasi-experimental (pre- and post-tests) or randomized controlled trial designs, through three objectives: First, to determine the characteristics of TPB-based interventions and their reported impact on smoking behavior and TPB variables (i.e., attitude, subjective norm, PBC, intention). Regarding the existing reviews and meta-analyses (e.g., Hardeman et al., 2002; Steinmetz et al., 2016), this work appears as the first to inform on the efficacy of TPB-based interventions specifically on smoking behavior. Moreover, the present review will also provide a detailed insight into the ways and contexts in which the TPB was used to change smoking behavior. Second, to evaluate the level of methodological quality of the included studies (e.g., design, data collection methods). This point appears of particular importance as it gives some crucial information about the validity of the results presented and the robustness of the conclusions that can be drawn from this review. Third, to assess the quality of the theoretical implementation in the included studies. As pointed out by some authors (Michie and Prestwich, 2010), implementing a theory-based intervention protocol is a rigorous scientific process that can be evaluated to determine to what extent the theory was used to develop the intervention, to explain intervention effects, and to provide considerations for future theory-based research. Nevertheless, Prestwich et al. (2014) reported in a meta-analysis that theories were rarely used extensively to develop or evaluate physical activity and healthy eating interventions. This review will explore how the TPB was implemented in smoking interventions.
Section snippets
Inclusion and exclusion criteria
Studies were included in the present systematic review if they met the following criteria: (i) the primary component or one of the components of the intervention targeted smoking behavior, (ii) the intervention implemented was based on the TPB (i.e., TPB had to be explicitly named in the text), (iii) smoking behavior or intention related to smoking behavior was measured at least at post-intervention time point. The exclusion criteria were (i) studies only evaluating the intention of subjects to
Search results
Fig. 1 displays the process of study selection. The four search strategies used in this systematic review initially returned a total of 8279 articles. Based on the screening of titles and abstracts, a total of 7039 articles were excluded using the following criteria: (i) not an intervention and/or not about tobacco, (ii) other languages than English or French. After having removed the duplicates between the four search strategies, 536 full-text articles were screened. A total of 519 articles
Discussion
The present systematic review is the first to specifically focus on TPB-based interventions on smoking behavior. A total of 17 studies were identified, which is lower than the number of observational studies identify (n ≥ 27) when TPB is used to explore determinants of smoking behavior (McEachan et al., 2011; Topa and Moriano, 2010). The publication of the results of the included studies mainly begins after 2010. The use of the TPB to design and evaluate programs targeting smoking behavior
Conclusion
This systematic review appears as the first to specifically focus on TPB-based interventions targeting smoking behavior. The proportion of studies that reported a significant impact on smoking behavior, intention, attitude, subjective norm, or PBC appeared relatively modest (42%–50%). Moreover, numerous flaws have been identified, both regarding methodological aspects and the theoretical implementation of the interventions. Future research should be aware that theory-based interventions have
Funding sources
Olivier Lareyre and Mathieu Gourlan were supported by the SIRIC Montpellier Cancer (Grant INCa-DGOS-Inserm 6045). The funding source had no role in the collection, analysis and interpretation of data, or the right to approve the finished manuscript prior to publication.
Declaration of Competing Interest
The authors declare that there are no conflicts of interest.
References (67)
The theory of planned behavior
Organ. Behav. Hum. Decis. Process.
(1991)- et al.
Preventive health behavior change text message interventions: a meta-analysis
Am. J. Prev. Med.
(2017) - et al.
Using meta-analytic path analysis to test theoretical predictions in health behavior: an illustration based on meta-analyses of the theory of planned behavior
Prev. Med.
(2016) - et al.
Measuring pathways towards a healthier lifestyle in the Hoorn Prevention Study: the Determinants of Lifestyle Behavior Questionnaire (DLBQ)
Patient Educ. Couns.
(2011) - et al.
A review of mediators of behavior in interventions to promote physical activity among children and adolescents
Prev. Med.
(2008) - et al.
The theory of planned behaviour and dietary patterns: a systematic review and meta-analysis
Prev. Med.
(2015) - Ajzen, I. (2006a). Behavioral interventions based on the theory of planned behavior....
- Ajzen, I. (2006b). Constructing a TPB questionnaire....
- et al.
The effect of web-based intervention on preventing tobacco smoking among male adolescents: an application of the theory of planned behavior
Ind. J. Fundam. Appl. Life Sci.
(2015) - et al.
Moderators of theory-based interventions to promote physical activity in 77 randomized controlled trials
Health Educ. Behav.
(2017)
Methods and processes of the CONSORT Group: example of an extension for trials assessing nonpharmacologic treatments
Ann. Intern. Med.
A theory-based online health behaviour intervention for new university students (U@Uni:LifeGuide) : results from a repeat randomized controlled trial
Trials
Helping Chinese fathers quit smoking through educating their nonsmoking spouses: a randomized controlled trial
Am. J. Health Promot.
Predicting and changing health behaviour: A social cognition approach
How well does the theory of planned behaviour predict alcohol consumption? A systematic review and meta-analysis
Health Psychol. Rev.
Evaluating non-randomised intervention studies
Health Technol. Assessment
Waterpipe smoking in the male college students: an education intervention using theory of planned behavior
J. Res. Health
Improving the reporting quality of nonrandomized evaluations of behavioral and public health interventions: the TREND statement
Am. J. Public Health
A theory-based online health behavior intervention for new university students: study protocol
BMC Public Health
A theory-based online health behaviour intervention for new university students (U@Uni): results from a randomised controlled trial
BMC Public Health
Development of theory-based health messages: three-phase programme of formative research
Health Promot. Int.
An intervention to increase compliance with a tobacco-free university policy
Am.J. Health Promo.
Constructing Questionnaires Based on the Theory of Planned Behaviour: A Manual for Health Services Researchers
Increasing anti-tobacco industry attitudes among youth: a pilot study of a multiplayer educational board game
Games Health J.
Tobacco Questions for Surveys: A Subset of Key Questions from the Global Adult Tobacco Survey (GATS)
Efficacy of theory-based interventions to promote physical activity. A meta-analysis of randomised controlled trials
Health Psychol. Rev.
The trans-contextual model of autonomous motivation in education: conceptual and empirical issues and meta-analysis
Rev. Educ. Res.
Application of the theory of planned behaviour in behaviour change interventions: a systematic review
Psychol. Health
Differences between participants and non-participants in an RCT on physical activity and psychological interventions for older persons
Aging Clin. Exp. Res.
Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide
BMJ
The effect of faith-based smoking cessation intervention during Ramadan among Malay smokers
Qatar Med. J.
Tobacco dependence treatment for Korean Americans: preliminary findings
J. Immigr. Minor. Health
A culturally adapted smoking cessation intervention for Korean Americans: a mediating effect of perceived family norm toward quitting
J. Immigr. Minor. Health
Cited by (32)
Participation in individual and collective agri-environmental schemes: A synthesis using the Theory of Planned Behaviour
2024, Journal of Rural StudiesBreaking barriers to rehabilitation: the role of behavior change theories in overcoming the challenge of exercise-related behavior change
2023, Brazilian Journal of Physical TherapyEfficacy of theory-based interventions aimed at reducing binge drinking in adolescents: A systematic review and meta-analysis of randomised controlled trials
2023, Social Science and MedicineCitation Excerpt :Of note, the social learning theory (Bandura, 1977; Botvin and Griffin, 2014) and social norms theory (Berkowitz, 2005) are also frequently mentioned theories to impact alcohol use (Black et al., 2016; Dietrich et al., 2016; Garnett et al., 2018; Tebb et al., 2016). Implementing and evaluating theory-based interventions is recognised to have several benefits (Hagger and Weed, 2019; Lareyre et al., 2021; Michie et al., 2018; Michie and Prestwich, 2010). First, such an approach allows identifying the key target constructs and selecting appropriate intervention techniques (Michie and Prestwich, 2010).
Factors associated with the patient privacy protection behaviours of nursing interns in China: A cross-sectional study
2022, Nurse Education in PracticeCitation Excerpt :Patient privacy protection cognition was related to patient privacy protection behaviours among nursing interns; this is similar to Ju’s finding (J.Y. Park and Woo, 2021). According to the theory of planned behaviour, potentially changeable cognitions can influence behaviours (Lareyre et al., 2021). Therefore, nursing interns with a strong cognition of patient privacy protection have the potential to better understand its importance, which may improve their privacy protection behaviours with patients.
Incorporating motivation and execution into healthy building rating systems based on the theory of planned behaviour (TPB)
2022, Building and EnvironmentCitation Excerpt :It mainly focuses on exploring the formation of motivation to engage in social traffic safety behaviour [41,43–45], pro-environmental and green behaviour (including travel by mass transit [42,46–48], energy saving and emission reduction behaviour [49–51], green purchasing behaviour [52], resource conservation and protection [53,54]), etc., in recent years. Moreover, previous reviews and meta-analyses have reported that TPB has also been used as a theoretical framework for designing health behaviour interventions, including smoking cessation [55], reducing risky sexual behaviours [56], promoting physical activity [57], maintaining a healthy diet [58], etc. However, few papers have systematically studied health-related behaviours and explored design strategies for workplace environments based on this theory.