The flow of information through the rapid realist review process is shown in Figure 1.
Figure 1. PRISMA flow diagram of articles through the rapid realist review process.
aThere were a total of seven studies that were pre-identified for theory development; however one of the seven studies was published in 2013; which is within the timeframe for the literature search (2005 – 2017) and thus counted in this flow diagram as a part of the total number of studies from the literature search.
A descriptive overview of all the interventions is provided in Table 1. Table 2 outlines the contexts, activities, and mechanisms used by interventions with statistically significant long-term (at five months follow-up or longer) smoking cessation outcomes.
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Exploration of the differences and commonalities among the interventions reveals several trends. For example, all interventions that took place in Africa (n=2) addressed only three behaviours and these behaviours did not include alcohol, stress, or sleep. Furthermore, none of the interventions in Africa use motivation as a mechanism. There was only one multiple health behaviour change intervention that took place in Central/South America (n=1). This intervention was conducted in a clinical setting and was designed to address four behaviours simultaneously. On the other hand, Europe (n = 60) and North America (n = 49) had larger variations in the number and types of behaviours addressed by any given intervention. Europe and North America were the only continents in which sleep was also targeted within behavioural change interventions. North America was also the only region in which there were interventions that targeted all six behaviours simultaneously.
Overall, the majority of interventions employed at least 2 mechanisms. Specifically 31(22%) interventions only used one mechanism, 66 (48%) of interventions used two mechanisms, and 41 (30%) targeted all three mechanisms. As shown in Table 1, 66 studies (48%) were scored as 4 stars, 59 (43%) were three stars, and 13 (9%) were scored as two stars. Common reasons for why studies scored less than four stars included: lack of clarity around whether bias was sufficiently addressed, use of non-validated measures, insufficient description of randomization process (if applicable), high withdrawal/drop-out.
Demi-Regularity – Opportunity
For the purposes of this rapid realist review, “opportunity” was defined as “all the factors that lie outside the individual that make the behaviour possible or prompt it” [31]. When interventions focused on increasing the “opportunity” to access services and change the social environment, tobacco users who engaged in other unhealthy behaviours were more likely to achieve long term smoking cessation. In particular, interventions that: 1) provided access to healthy living “tools” (e.g. free medications such as nicotine replacement therapy, gym memberships, walking groups, free/accessible fruits and vegetables, etc.) and/or 2) encouraged social support (e.g. incorporating family members into care, interventions held social events).
Supporting evidence. There were 32 interventions [40, 56-86] that used opportunity as one of the mechanisms for behaviour change with the majority of these interventions (59%) [40, 65-78, 81-84] reporting successful long term cessation. There were 12 interventions that aimed to increase access to resources as a part of the intervention [60, 62, 65, 66, 69, 70, 76, 77, 81-84]. Of these 10 (83%) interventions reported successful long term smoking cessation [65, 66, 69, 70, 76, 77, 81-84]. The majority of interventions that made changes to the physical and/or social environment (8/11; 73%) [40, 65, 66, 68, 73, 81, 82, 84] or interventions that improved patient’s social support system (10/15; 67%) [65-68, 71, 72, 74-76, 78] also reported successful long term cessation.
In various settings (e.g. clinical settings, community settings, workplace, etc.) and across several continents, programs that aimed to increase the opportunity to change behaviours were successful in achieving long term smoking abstinence among their participants (Table 3). These trends remain fairly consistent when examining all interventions; including those interventions that were rated from one to three stars in our quality assessment and reported statistical significance (see Additional File 3).
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Demi-Regularity – Capability
For this review, capability was defined as the “individual's psychological and physical capacity to engage in healthy behaviours” [31]. The success of interventions that included capability as a mechanism appears to be dependent on various factors, including: the specific context in which these interventions were implemented, the populations that were targeted, and the types of behaviours targeted in the intervention. When examining specific techniques for increasing capability, including “capacity to plan”, “enhancing knowledge” and “empowerment”, the effectiveness of these techniques is dependent on the context in which it is implemented.
Supporting evidence. Of the 53 interventions in our sample that were based on this mechanism [12, 40, 43, 56-105], only 23 (43%) interventions resulted in long term smoking cessation [40, 65-78, 81-84, 102-105]. Unlike the trends observed with opportunity, the majority of interventions that used capability as one of the mechanisms were not successful. These trends persisted when we looked at specific techniques for increasing capability. Only one [71] out of the four interventions [64, 71, 89, 90] that sought to change to one’s beliefs about the intervention (a technique used to increase capability) reported successful long term smoking cessation.
However, there were certain contexts in which interventions based on this mechanism observed more success. Specifically, interventions that took place in Asia; four [67, 71, 84, 103, 104] out of eight interventions [59, 63, 67, 71, 80, 84, 103, 104] reported participants were more likely to quit smoking. Interventions that utilized capability in community based settings or in schools also had positive results with 71% (5/7) [40, 70, 77, 81, 104] and 80% (4/5) [40, 73, 82, 84], respectively reporting long term smoking cessation.
There was only one observable trend among interventions that used capability to target primary prevention or secondary prevention. Interventions that targeted secondary prevention and aimed to empower participants did not appear to be effective. Only two (40%) [67, 71] out of the five interventions [67, 71, 92, 94, 99] reported successful long term smoking cessation.
Conversely, there were certain contexts in which using capability as a mechanism appeared to negatively impact the success of the intervention. In Europe (6/19; 32%) [40, 70, 74, 78, 83, 102] and in Australasia (2/5; 40%) [69, 75], only a minority of the interventions using capability reported participants were more likely to quit smoking. Even when we examined specific techniques for increasing capability that were used in Europe, very few interventions reported successful long term smoking cessation. Similar trends were observed with interventions that took place in clinical settings; only 37% (10/27) [40, 67, 71, 76, 78, 81, 83, 102-104] of the interventions reported participants were more likely to quit smoking.
The type and number of risk behaviours targeted by interventions that aimed to increase patient’s capability were also examined (Table 4). Unlike what was observed for opportunity, using capability as a mechanism in an intervention only appeared to be successful for certain behaviours and when specific techniques for increasing capability were used. For example, among interventions that targeted stress, the majority of interventions (6/10; 60%) [40, 65, 66, 68, 75, 83] that used ‘capacity to plan’ demonstrated success in achieving long term smoking cessation. Furthermore, 60%; (3/5) [65, 71, 75] of interventions that targeted alcohol and used ‘empowerment’ as a technique for increasing capability reported long term smoking cessation. However, only 33% (1/3) of interventions [71] that targeted alcohol and used the technique of changing ‘beliefs about the intervention’ reported long term smoking cessation.
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Demi-regularity – Motivation
Motivation, defined as “all those brain processes that energize and direct behaviour, not just goals and conscious decision-making” [31], appears to be effective in certain contexts for improving smoking cessation outcomes.
Supporting evidence. Thirty seven interventions [12, 40, 43, 56, 58, 59, 61, 64-66, 68, 70, 75-80, 83, 84, 86, 89, 90, 92, 93, 95-97, 99-103, 105-108] in our sample were based on a specific theory that increasing a patient’s motivation would assist in quit smoking. Based on our criteria, there were very few techniques involving motivation that had any reportable trends. As a result, we have chosen to provide a descriptive overview of the trends for the overall motivation mechanism.
Interventions that included a component for increasing participant’s motivation had mixed results, as 43% (16/37) [40, 65, 66, 68, 70, 75-78, 83, 84, 102, 103, 105, 107, 108] of studies reported an association between increasing participant’s motivation and long term smoking cessation. Similar to capability, implementing strategies that increased motivation within interventions appeared to be beneficial in certain contexts. For example, the majority of interventions that utilized motivation in community-based settings (3/4; 75%) [40, 70, 77] and schools (2/3; 67%) [40, 84] reported that participants were more likely to quit smoking long term. In contrast, applying motivation as a mechanism was unsuccessful in clinical settings; eight (36%) [40, 76, 78, 83, 102, 103, 107, 108] out of the 22 [12, 40, 43, 58, 64, 76, 78-80, 83, 86, 89, 92, 93, 95, 99, 100, 102, 103, 106-108] interventions in these settings reported participants were more likely to quit smoking.
In terms of the number of behaviours that were targeted, interventions targeting three behaviours demonstrated limited success; only six (32%) [77, 78, 84, 102, 103, 107] of the 19 [12, 61, 64, 77-80, 84, 86, 92, 93, 95, 96, 99, 100, 102, 103, 106, 107] reported long term smoking cessation. The types of behaviours targeted by these interventions were also examined. The majority of interventions that focused on increasing patient’s motivation and targeted stress (8/12; 67%) [40, 65, 66, 68, 70, 75, 83, 105] reported a greater likelihood of long term smoking cessation.