Elsevier

Preventive Medicine

Volume 143, February 2021, 106327
Preventive Medicine

Review Article
Characteristics and impact of theory of planned behavior interventions on smoking behavior: A systematic review of the literature

https://doi.org/10.1016/j.ypmed.2020.106327Get rights and content

Highlights

  • A systematic review of TPB-based interventions on smoking behavior was performed.

  • A total of 17 studies met the inclusion criteria.

  • Proportion of studies with an impact on behavior or TPB variables ranged 42%–50%.

  • Flaws were found regarding methodological quality and theoretical implementation.

  • Future TPB-based interventions should be implemented in a more rigorous manner.

Abstract

Theoretical frameworks such as the theory of planned behavior (TPB) can be applied to design and evaluate smoking behavior interventions. The present systematic review aimed to: (i) determine the characteristics of TPB-based interventions and their reported impact on smoking behavior and TPB variables, (ii) evaluate the level of methodological quality in the included studies, and (iii) assess the quality of the theoretical implementation. Studies were eligible for inclusion if the intervention targeted smoking behavior, was explicitly based on the TPB, and if smoking behavior or intention was measured at least at post-intervention. Relevant articles were identified through searches on databases and internet search engines, responses to messages sent on thematic forums, consultation of prominent authors, and manual searches on key websites and key TPB-publications. Seventeen studies met the inclusion criteria. A majority of studies (65%) targeted the student population (i.e., elementary school, high school, university). Interventions minimally included the provision of health messages. The proportion of studies that reported a significant impact on smoking behavior, intention, attitude, subjective norm, or PBC ranged between 42% and 50%. Regarding methodological quality, unclear or high risks of bias were notably found regarding the selection of participants, data collection methods, withdrawal and drop-outs, and blinding. Regarding theoretical implementation, the reciprocal link between intervention techniques and TPB variables targeted remain unclear for a majority of studies. To better inform tobacco prevention and TPB research, future studies should more systematically use rigorous methods when designing, implementing, and reporting TPB-based interventions.

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.

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