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One size fits all? A process evaluation—the turn of the ‘story’ in smoking cessation
ARTICLE IN PRESS Public Health (2007) 121, 341–348
www.elsevierhealth.com/journals/pubh
Original Research
One size fits all? A process evaluation—the turn of the ‘story’ in smoking cessation D. Ritchiea,, S. Schulzb, A. Brycec a
School of Health in Social Science, University of Edinburgh, Teviot Place, Edinburgh, Scotland, UK School of Health and Social Science, Queen Margaret University College, Edinburgh, Scotland, UK c NHS Argyll and Clyde, Scotland, UK b
Received 7 April 2006; received in revised form 14 November 2006; accepted 4 December 2006 Available online 9 February 2007
KEYWORDS Smoking cessation; Narratives; Community health promotion; Low income
Summary Objectives: This qualitative process evaluation aimed to make explicit the assumptions shaping the practice of smoking cessation groups using the medium of the story, and assessed the smokers’ perceptions of the value of the new method in their attempts to quit smoking. Study design: This narrative analysis represents a holistic-content perspective and considers the multiple narratives of the smoking cessation groups, as both context and content, and provides unique insights into the assumptions that inform smoking cessation. The analysis of stories is ‘‘a unique means to get inside the world of health promotion practice’’ (Riley T, Hawe P. Researching practice: the methodological case for narrative inquiry. Health Educ Res 2005;20:226–36). Methods: Data were firstly collected by observing a snapshot of 12 existing smoking cessation groups in a low-income community over six weeks. Secondly, five debriefing sessions were held with the group facilitator to unpack the assumptions informing the practice. Thirdly, 11 interviewees were purposively selected out of a total group sample of 67 in order to assess their perceptions and experience of the groups. These 11 interviewees were people who had made use of the service at least three times within six consecutive months. Results: The findings of this study challenge current smoking cessation guidelines (West R, McNeill A, Raw M. Smoking cessation guidelines for Scotland 2004 update. Edinburgh, Scotland: ASH Scotland and NHS Health Scotland; 2004) and suggest highly structured standardized 6–8 week programmes in smoking cessation are insufficient to meet the needs of many smokers. Stories are used to both locate the process of change within people’s daily lives as well as to enable people to engage in a supportive process with others. The intention to change is perceived by many smokers to be unstable and requires opportunities for longer-term support. Flexibility in their attendance and ongoing support to both make the decision to stop and stay stopped is clearly valued by the participants. In addition, including people at the different stages of change seems to be positive and the participants
Corresponding author. Tel.: +44 0 131 6503894.
E-mail address: [email protected] (D. Ritchie). 0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.12.001
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D. Ritchie et al. appear to incorporate without difficulty those who are still smoking with those who have stopped. Many find the insights of those at the different stages very valuable in their own attempts to quit. Current practices of excluding smokers who are still unsure of their own motivation are challenged. Conclusions: The hypotheses generated by the work suggest that flexible services that offer support to a range of smokers are beneficial and valued. In addition, programmes that are tailored to the individual’s context and culture, as well as the individual’s personal life situation, through the medium of the story, are valued and acceptable to the participants. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Current Scottish policy and practice Many smokers, particularly those who are defined as not motivated to quit, are potentially excluded from the dedicated specialist smoking cessation services in Scotland. Current smoking cessation guidelines emphasize assessment of the individual’s readiness to change and the need to set a quit date.2 These smoking cessation guidelines advise ‘‘both a structured face-to-face behavioural support and nicotine replacement therapy offered by specially trained staff. The support can be offered in groups or individually’’.2 There is accepted evidence of the effectiveness of these approaches.2 Treatment packages that combine intensive support with nicotine replacement therapy (NRT) have been shown to increase long-term abstinence rates to 16% over controls for at least six months.3,4 However, this rate of effectiveness does mean that many smokers are not able to quit effectively and suggests that new methods need to be explored, particularly for low-income smokers and those most heavily addicted. The assessment of motivation and readiness to quit demonstrated by the setting of quit dates suggests the implicit influence of the ‘stages of change’ model5 in current guidelines and may present a barrier to many smokers. A systematic review of the effectiveness of stage-based interventions suggests that there is limited evidence of effectiveness, and this may be due to the uncritical use of theory.6 The stage-based methods are very popular with both practitioners and policy-makers and there are many claims in the literature about its potential and dominant impact upon health promotion.7,8 There are, however, many well-rehearsed robust critiques of the stages of change methods and these include many debates about the validity of the description of the stages of change and the utility
of the model.7,9–20 Importantly the implementation of the stages of change model ignores any influences on smoking other than behaviour, and indeed simplifies the complexity of behaviour within a cultural context.11–13 Although there are limitations in contextualizing local cultures,7–20 they continue to be the dominant approach, along with pharmacological treatment in smoking cessation.2,3 Others7 urge for qualitative case studies to be undertaken to provide process-based evaluations of the microanalysis of smoking cessation practice in order to explore how and what works.
Interventions in low-income areas The current smoking cessation guidelines tend to be standardized in structured protocols and are not fully adapted to meet the needs of different target groups or cultures.2 Indeed the evidence for effective approaches for lower income smokers remains weak and is largely based on descriptive studies or pilot studies.2 However, work from projects in England suggests that services need to provide intensive support and offer flexible delivery and accessibility.21,22 Furthermore, smokers who are heavily dependent require more support.23
Significance of community norms in smoking A number of studies have demonstrated the importance of the context of people’s smoking behaviour. These studies have demonstrated that the daily contexts of people’s lives and strong community norms towards smoking can facilitate a positive smoking culture that can in turn constrain and undermine cessation interventions.24,25
Background The case study—‘Smokey Joe’—was identified by the local National Health Service (NHS) smoking
ARTICLE IN PRESS The turn of the ‘story’ in smoking cessation cessation co-ordinator as an area of practice that had raised a number of questions. Firstly, it appeared to be sustaining contact with smokers who would normally not be encouraged to use the service in a low-income area. Secondly, it was considered important for the practitioner to be supported to articulate the assumptions informing his practice. The service offers flexible access to any smoker during any stage of their quit process, encourages access through general practitioner (GP) and self-referral, and is largely accessed through word of mouth in the community.
Narrative therapy ‘Smokey Joe’ has adopted some elements from narrative therapy as a complementary approach to the stage-based model for smoking cessation group work. Narrative therapy is a therapeutic process whereby people are invited to tell their own ‘self’-story.26 Our self-stories are situated within a particular social and political context. This means that the stories we tell are constructed and contingent upon these contexts.27,28 The notion of the ‘dominant story’ is an important one in narrative therapy.27,28 Narrative therapists argue that each of us has dominant self-stories, i.e., we draw on specific recurring discursive repertoires to present ourselves to others.27,28 For example, when smokers talk about their smoking they tend to draw on discursive repertoires of established stories and metaphors. At times, our dominant self-stories can be limiting or damaging to us, for example if we develop self-stories in which we are powerless or lacking resources and strength. However, all dominant self-stories contain some elements that can be used to construct alternative, more positive and empowering versions of our self-story. This qualitative process evaluation aims to make explicit the assumptions shaping the practice of smoking cessation groups using narrative therapy, as well as assess the smokers’ perceptions of the value of the method in their attempt to quit smoking. The evaluation is based upon a microanalysis of the interventions and accounts of both the therapist and the participants in smoking cessation groups. In this paper we argue that an understanding of the local culture and the community smoking norms should shape cessation interventions. By offering stories that are situated and contingent upon the local culture, the medium of the story can facilitate a more culturally attuned approach to smoking cessation.
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Methods Narrative analysis is a research method that can enable us to explore how self-identity is socially constructed.28 It contends that stories, whilst drawing upon a discourse of self, depend upon the interactions of others to help shape and alter the stories and render them intelligible.28 Some traditions of narrative analysis situate the analysis of the story within an historical and cultural perspective. It is this aspect of meaning making that is relevant to a research question that has a primary focus of exploring the cultural meaning making systems of the shared communal and individual smoking story. The smoking narrative is ‘‘immersed within a process of ongoing interchange’’ that is historically and culturally contingent.29
Stories and health promotion It is strongly argued that the story/dialogue is a useful method as a tool for evaluation29 and it has assisted practitioners to make explicit the assumptions (theory) that they use in their work and to subject them to scrutiny. Recent work1 suggest that the analysis of stories is ‘‘a unique means to get inside the world of health promotion practice’’,1 and as such will provide us with unique insights into the assumptions that inform smoking cessation practice. In this study it was important to use methods that capture and make explicit the process and assumptions shaping the smoking cessation groups.
Research sample Data were firstly collected by observing a snapshot of 12 existing smoking cessations groups in a lowincome community in Scotland over a six-week period, from October to December 2003. Secondly, five debriefing sessions were held with the group facilitator to unpack the assumptions behind the approach. Thirdly, 11 interviewees were selected purposively out of a total group sample of 67, in order to assess their perceptions and the impact of the groups on their smoking. These 11 interviewees had made use of the service at least three times within six consecutive months, namely between June and December 2003. At the same time as this process evaluation was conducted, the NHS commissioned a study that surveyed a sample of 114 clients who used the ‘Smokey Joe’ service in 2003.30
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Ethical approval was provided by the local NHS ethics committee, as the participants were patients of existing services. Consent was obtained from all smoking cessation group members, as the researcher observed the group. To ensure confidentiality, participant names have been replaced with pseudonyms.
Impact evaluation—individual interviews
Process evaluation: group observations
Data analysis
Participants were from existing smoking cessation groups located in the Health Centre. On average these groups consisted of 11 clients, with the largest group comprising 19 and the smallest two. Over the six-week period 67 different clients made use of the smoking cessation groups, 49 of whom were female and 18 male. Clients ranged in age between 20 and 77 years, with the majority being between 30 and 69 years of age. By cross-referencing client postcode information with data from the ‘‘Scottish indices of 2003’’ data zones, we can see in Table 1 that clients came from data zones that fall into the Scottish index of multiple deprivation (SIMD) deciles 2–10. Splitting the deciles into the five most deprived (deciles 1–5) and most advantaged ones (deciles 6–10), respectively, suggests that our sample is fairly evenly distributed between the more deprived and more advantaged zones. Thus, we find 31 clients living within SIMD deciles 1–5, while 29 reside in SIMD deciles 6–10. This mixed social group was surprising as the area of the study is recognized as a lowincome area.
The analysis represents a holistic-content perspective.31 In this case it involved considering the multiple narratives of the smoking cessation groups as both context and content. A number of quality practices were used to develop rigour in this qualitative research. Firstly, the researchers were reflective as both data collectors and analysts, and considered their own values and positions regarding smoking. Secondly, there was a deep immersion in the data that provided the richness of detail ‘‘in the data and the analysis’’.32 The quality of the detail was also enhanced by good transcription, supported by detailed field notes. All group sessions and interviews were transcribed and converted to a format suitable for analysis using the software package QSR N6 (QSR International). Based on the field notes for the group observations and the individual interviews a number of recurrent meta-narratives in relation to the overall group story and process, as well as each individual’s quitting story, were identified. The meta-narratives were used as a framework for more focussed coding to identify sub-narratives
Table 1 The split of group observation clients according to Scottish index of multiple deprivation (SIMD) deciles.
Table 2 Split of postgroup sample according to Scottish index of multiple deprivation (SIMD) deciles.
SIMD deciles
Number of clients per SIMD decile
SIMD deciles
Number of attendees per SIMD
SIMD 1 (most deprived) SIMD 2 SIMD 3 SIMD 4 SIMD 5 SIMD 6 SIMD 7 SIMD 8 SIMD 9 SIMD 10 (most affluent) Total number of clients included Missing data
0 16 6 4 5 12 6 4 0 7 60
SIMD 1 (most deprived) SIMD 2 SIMD 3 SIMD 4 SIMD 5 SIMD 6 SIMD 7 SIMD 8 SIMD 9 SIMD 10 (least deprived) Total number of attendees included Missing data
2 2 1 2 1 0 0 0 0 3 11
7
The 11 interviewees were between 36 and 68 years of age, with an average age of 53, and consisted of nine women and two men. The split of this group sample according to SIMD deciles is shown in Table 2.
0
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within each meta-narrative. Other publications provide a full microanalysis of all these narratives.33 In this paper we focus on the perceived effectiveness of the use of the stories in smoking cessation as well as the value of flexible service delivery.
Perceptions of the service
Results Effectiveness Follow-up of the 11 interviewees indicated that at the time of the interview only two interviewees were smoking, one smoked two cigarettes and the other between 10 and 20 cigarettes a day. Six of the other interviewees had had brief relapses over Christmas and/or New Year, which meant that at the time of the interview they had stopped smoking for between 5 and 7 weeks. The remaining three interviewees had not smoked for 9, 7 and 4 months, respectively. The clients’ original and current smoking behaviour is summarized in Table 3. It should be noted that by selecting attendees who had made use of the service at least three times within six consecutive months, namely between June and December 2003, there is the potential that we selected people with a bias towards a positive outcome. Furthermore, the retrospective monitoring study conducted by GSR (2004) suggested that the monitoring of a sample of 114 clients (40% response rate) who used the ‘Smokey Joe’ service in 2003 indicated a quit rate of 16% and that this quit rate had been sustained at the 12 month follow up,30 however this rate does not represent an intention
Table 3
to quit rate, as within the current monitoring arrangements this was difficult to achieve due to the retrospective design of the monitoring and also the mixed composition of the groups that consisted of smokers deciding to quit, those who have quit and those who have relapsed.
Flexibility Clients valued the friendly, non-judgmental atmosphere and emphasized that this created an open and trusting environment in which they felt comfortable discussing their successes as well as their setbacks. The approach allowed clients to make their own decision when to stop. There is no time scale in which they have to achieve a nonsmoking status, nor is there a time limit for group membership. Clients valued the flexibility of the service which allowed them to make use of it when they could and when they most felt they needed it. Not surprisingly perhaps, the open-ended nature of this service invites clients to regard stopping as a long-term commitment, which may require longterm support. Extract 1: Peter: I said to him [the group facilitator] y I said, when do I get thrown out? I feel a wee bit embarrassed. Maybe I shouldn’t feel embarrassed. I don’t know. But they all say, that’s four weeks and three weeks or two weeks or two days or a day and I go y seventeen weeksy I said when do I get thrown out? Terry said, ye never get thrown out of here, ye can come back and forward as ye like, ye know. So I felt quite
Interviewees’ original and current levels of consumption.
Pseudonym
SIMD decile
Original consumption level
Current consumption level
Number of times attended in 6 months
Group attendance
Gill Muriel Melanie Dan Margaret Fiona Annabelle Peter Anne Rhona Tania
1 1 2 2 3 4 4 5 10 10 10
10–15 a day 40 a day 20 a day 12 cigars a day 11–13 a day 20 a day 30 a day 30 a day 30–40 a day 20 a day 40 a day
2 a day None, quit 9 None, quit 5 None, quit 5 None, quit 7 None, quit 6 10–20 a day None, quit 4 None, quit 7 None, quit 7 None, quit 5
3 4 5 3 8 4 4 3 9 4 3
Yes One-to-one Yes Yes Yes Yes No Yes Yes Yes Yes
Scottish index of multiple deprivation, SIMD.
months ago weeks ago weeks ago weeks ago weeks ago months ago months ago weeks ago weeks ago
ARTICLE IN PRESS 346 happy at that, ye know. He said, you just keep coming son, you just keep coming. Client need for long-term support can also be seen in the extract below in which the interviewee talks about how they intend to make use of the service in the future. Extract 2: Dan: y I don’t think I’ll be one of these people that maybe come for three months. And then say I don’t need to go there any more. I see this as a long-term thing. And I will continue coming for as long as possible. Mixed groups—smokers at different stages An important reason why the group seems to work so well as a source of support for clients lies in the fact that the groups are mixed, i.e., that long-term attendees and newcomers, as well as people who are still smoking and those who have stopped are all in the same group. Interviewees described people who have given up smoking, yet continue coming to the group, as providing them with motivation to stop, or as a kind of ‘positive’ template that they were aiming to emulate when they first started going to the group. Extract 3: Rhona: I think it’s quite good that the group’s quite varied. y So it’s quite good to see people that were succeeding and that kind of thingy if it was a sort of y these classes start this date and end that date. I don’t think that would be very good. I think the fact that they are kinda mixed up and ongoing is betteryBut if you said, oh you have to go to the anti-smoking class this week and it lasts for 6 weeks and everybody was at the same stage, I don’t think it’d be the same. I think it’s quite good to see people at all different kinda stages. Using stories Stories and metaphors are used in the groups as vehicles for change. Story telling is a common way of gaining attention and interest. The language used and the types of stories told reflect the context of the local culture. Engaging group members in each other’s stories about smoking and stories of quitting smoking are an important part of the change process. This becomes clear in the following extract from one of the debriefing sessions with the group facilitator. Extract 4: Researcher: y story telling is not just about the story. It’s about the person who tells the story as well and the manner in which the story’s told. So
D. Ritchie et al. first of all, I was wanting to ask you a bit about that. What do you think are the functions of the stories that you tell yourself, you know, what are you trying to do when you’re telling stories, as you do? And the other thing is what do you think is the function of getting the participants to tell their own stories? Group facilitator: The reason I’m telling a story is its communication. Straight into the person’s mind that breaks down barriers. So in other words, if you gave a lecture by giving the facts about smoking, just hard numbers, 320 people die every day and so on and so forthy. Within seconds, within milliseconds with some clients, they will switch off and not hear anything because their mind will wander onto everyday thingsyNow if you start to tell a story and if you think for instance where, say you start to tell a personal story about something you did on a night out or someone else has done on a night outy so you don’t stop there, I need to know more, I want more. And when you are telling a story, the client is hanging on every word, processing and understanding every word that’s going onyAnd they will listen right to the last full stop because they want to know the ending. So in terms of getting information across to assist a client to do whatever they want to do, it’s definitely a great mediumySo that’s what we’re doing here with the story because stories are patterns, so it’s expected y they almost know before they go to the pub the story of that pub. So you’ve got to run with itySo that they recognize their own part as an actorySo we’re talking in here in terms of factual information and just giving facts doesn’t do the job but about trying to kind of embrace and engage in people’s stories is the kind of thing that people recognise and, you know, as something that they would normally do in their own lives, particularly anything that would have engaged them anyway. Equally the participants in the group valued the way story enables them to engage with the process. And the participation and engagement with each other’s stories sustained them in their quit attempt. Extract 5: Margaret: y I will go down because I think people want to hear. Hear how you’re doing and you want to hear how everybody else is doing. You want to see how everybody’s getting on. y I think you quite look forward to coming down and hearing all the stories.
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Discussion
Acknowledgements
The case study, although limited to one context, has offered the opportunity to respond to calls for qualitative case studies to be undertaken to provide process-based evaluations of practice. It aimed to make explicit the assumptions shaping the practice of smoking cessation groups using the medium of the story and assessed the smokers’ perceptions of the value of the new method in their attempts to quit smoking. The findings do provide approaches that may overcome the limitations of the current smoking cessation methods, particularly the limitations in contextualizing local cultures and influences on smoking other than behaviour. Firstly, this case study demonstrates an approach that incorporates the context, culture and realities of people’s lives, and stories are used to both locate the process of change within people’s daily lives as well as to enable people to engage in a supportive process with others. Secondly, the intention to change is perceived by many smokers to be unstable and requires opportunities for longerterm support. Flexibility in their attendance and ongoing support to both make the decision to stop and stay stopped is clearly valued by the participants and supports the findings from the English studies for the need for flexibility in smoking cessation in deprived areas.22,23 It should be noted, however, that the actual membership of the smoking cessation groups when analysed by postcode did find a surprising social mix with higher income attendees than expected in a low-income area. Thirdly, including people at the different stages of change seems to be positive and the participants appear to incorporate without difficulty those who are still smoking with those who have stopped. Many find the insights of those at the different stages very valuable in their own quit attempts. In summary the hypotheses generated by the work suggest that the ‘one size fits all’ approach of current practice is not always valued by all smokers, and flexible services that offer support to a range of smokers are as beneficial in terms of quit rates as the more ‘traditional’ structured and standardized programmes. In addition, programmes that are tailored to the individual’s context and culture, as well as the individual’s personal life situation through the medium of the story, are valued and acceptable to the participants. Further research is required in a range of contexts to test these hypotheses. New methods are needed for those who do not benefit from the more structured programmes.
‘Smokey Joe’ is one of 11 local pilot projects funded through Partnership Action on Tobacco and Health, part of ASH Scotland.
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www.elsevierhealth.com/journals/pubh
Original Research
One size fits all? A process evaluation—the turn of the ‘story’ in smoking cessation D. Ritchiea,, S. Schulzb, A. Brycec a
School of Health in Social Science, University of Edinburgh, Teviot Place, Edinburgh, Scotland, UK School of Health and Social Science, Queen Margaret University College, Edinburgh, Scotland, UK c NHS Argyll and Clyde, Scotland, UK b
Received 7 April 2006; received in revised form 14 November 2006; accepted 4 December 2006 Available online 9 February 2007
KEYWORDS Smoking cessation; Narratives; Community health promotion; Low income
Summary Objectives: This qualitative process evaluation aimed to make explicit the assumptions shaping the practice of smoking cessation groups using the medium of the story, and assessed the smokers’ perceptions of the value of the new method in their attempts to quit smoking. Study design: This narrative analysis represents a holistic-content perspective and considers the multiple narratives of the smoking cessation groups, as both context and content, and provides unique insights into the assumptions that inform smoking cessation. The analysis of stories is ‘‘a unique means to get inside the world of health promotion practice’’ (Riley T, Hawe P. Researching practice: the methodological case for narrative inquiry. Health Educ Res 2005;20:226–36). Methods: Data were firstly collected by observing a snapshot of 12 existing smoking cessation groups in a low-income community over six weeks. Secondly, five debriefing sessions were held with the group facilitator to unpack the assumptions informing the practice. Thirdly, 11 interviewees were purposively selected out of a total group sample of 67 in order to assess their perceptions and experience of the groups. These 11 interviewees were people who had made use of the service at least three times within six consecutive months. Results: The findings of this study challenge current smoking cessation guidelines (West R, McNeill A, Raw M. Smoking cessation guidelines for Scotland 2004 update. Edinburgh, Scotland: ASH Scotland and NHS Health Scotland; 2004) and suggest highly structured standardized 6–8 week programmes in smoking cessation are insufficient to meet the needs of many smokers. Stories are used to both locate the process of change within people’s daily lives as well as to enable people to engage in a supportive process with others. The intention to change is perceived by many smokers to be unstable and requires opportunities for longer-term support. Flexibility in their attendance and ongoing support to both make the decision to stop and stay stopped is clearly valued by the participants. In addition, including people at the different stages of change seems to be positive and the participants
Corresponding author. Tel.: +44 0 131 6503894.
E-mail address: [email protected] (D. Ritchie). 0033-3506/$ - see front matter & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2006.12.001
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D. Ritchie et al. appear to incorporate without difficulty those who are still smoking with those who have stopped. Many find the insights of those at the different stages very valuable in their own attempts to quit. Current practices of excluding smokers who are still unsure of their own motivation are challenged. Conclusions: The hypotheses generated by the work suggest that flexible services that offer support to a range of smokers are beneficial and valued. In addition, programmes that are tailored to the individual’s context and culture, as well as the individual’s personal life situation, through the medium of the story, are valued and acceptable to the participants. & 2006 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Current Scottish policy and practice Many smokers, particularly those who are defined as not motivated to quit, are potentially excluded from the dedicated specialist smoking cessation services in Scotland. Current smoking cessation guidelines emphasize assessment of the individual’s readiness to change and the need to set a quit date.2 These smoking cessation guidelines advise ‘‘both a structured face-to-face behavioural support and nicotine replacement therapy offered by specially trained staff. The support can be offered in groups or individually’’.2 There is accepted evidence of the effectiveness of these approaches.2 Treatment packages that combine intensive support with nicotine replacement therapy (NRT) have been shown to increase long-term abstinence rates to 16% over controls for at least six months.3,4 However, this rate of effectiveness does mean that many smokers are not able to quit effectively and suggests that new methods need to be explored, particularly for low-income smokers and those most heavily addicted. The assessment of motivation and readiness to quit demonstrated by the setting of quit dates suggests the implicit influence of the ‘stages of change’ model5 in current guidelines and may present a barrier to many smokers. A systematic review of the effectiveness of stage-based interventions suggests that there is limited evidence of effectiveness, and this may be due to the uncritical use of theory.6 The stage-based methods are very popular with both practitioners and policy-makers and there are many claims in the literature about its potential and dominant impact upon health promotion.7,8 There are, however, many well-rehearsed robust critiques of the stages of change methods and these include many debates about the validity of the description of the stages of change and the utility
of the model.7,9–20 Importantly the implementation of the stages of change model ignores any influences on smoking other than behaviour, and indeed simplifies the complexity of behaviour within a cultural context.11–13 Although there are limitations in contextualizing local cultures,7–20 they continue to be the dominant approach, along with pharmacological treatment in smoking cessation.2,3 Others7 urge for qualitative case studies to be undertaken to provide process-based evaluations of the microanalysis of smoking cessation practice in order to explore how and what works.
Interventions in low-income areas The current smoking cessation guidelines tend to be standardized in structured protocols and are not fully adapted to meet the needs of different target groups or cultures.2 Indeed the evidence for effective approaches for lower income smokers remains weak and is largely based on descriptive studies or pilot studies.2 However, work from projects in England suggests that services need to provide intensive support and offer flexible delivery and accessibility.21,22 Furthermore, smokers who are heavily dependent require more support.23
Significance of community norms in smoking A number of studies have demonstrated the importance of the context of people’s smoking behaviour. These studies have demonstrated that the daily contexts of people’s lives and strong community norms towards smoking can facilitate a positive smoking culture that can in turn constrain and undermine cessation interventions.24,25
Background The case study—‘Smokey Joe’—was identified by the local National Health Service (NHS) smoking
ARTICLE IN PRESS The turn of the ‘story’ in smoking cessation cessation co-ordinator as an area of practice that had raised a number of questions. Firstly, it appeared to be sustaining contact with smokers who would normally not be encouraged to use the service in a low-income area. Secondly, it was considered important for the practitioner to be supported to articulate the assumptions informing his practice. The service offers flexible access to any smoker during any stage of their quit process, encourages access through general practitioner (GP) and self-referral, and is largely accessed through word of mouth in the community.
Narrative therapy ‘Smokey Joe’ has adopted some elements from narrative therapy as a complementary approach to the stage-based model for smoking cessation group work. Narrative therapy is a therapeutic process whereby people are invited to tell their own ‘self’-story.26 Our self-stories are situated within a particular social and political context. This means that the stories we tell are constructed and contingent upon these contexts.27,28 The notion of the ‘dominant story’ is an important one in narrative therapy.27,28 Narrative therapists argue that each of us has dominant self-stories, i.e., we draw on specific recurring discursive repertoires to present ourselves to others.27,28 For example, when smokers talk about their smoking they tend to draw on discursive repertoires of established stories and metaphors. At times, our dominant self-stories can be limiting or damaging to us, for example if we develop self-stories in which we are powerless or lacking resources and strength. However, all dominant self-stories contain some elements that can be used to construct alternative, more positive and empowering versions of our self-story. This qualitative process evaluation aims to make explicit the assumptions shaping the practice of smoking cessation groups using narrative therapy, as well as assess the smokers’ perceptions of the value of the method in their attempt to quit smoking. The evaluation is based upon a microanalysis of the interventions and accounts of both the therapist and the participants in smoking cessation groups. In this paper we argue that an understanding of the local culture and the community smoking norms should shape cessation interventions. By offering stories that are situated and contingent upon the local culture, the medium of the story can facilitate a more culturally attuned approach to smoking cessation.
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Methods Narrative analysis is a research method that can enable us to explore how self-identity is socially constructed.28 It contends that stories, whilst drawing upon a discourse of self, depend upon the interactions of others to help shape and alter the stories and render them intelligible.28 Some traditions of narrative analysis situate the analysis of the story within an historical and cultural perspective. It is this aspect of meaning making that is relevant to a research question that has a primary focus of exploring the cultural meaning making systems of the shared communal and individual smoking story. The smoking narrative is ‘‘immersed within a process of ongoing interchange’’ that is historically and culturally contingent.29
Stories and health promotion It is strongly argued that the story/dialogue is a useful method as a tool for evaluation29 and it has assisted practitioners to make explicit the assumptions (theory) that they use in their work and to subject them to scrutiny. Recent work1 suggest that the analysis of stories is ‘‘a unique means to get inside the world of health promotion practice’’,1 and as such will provide us with unique insights into the assumptions that inform smoking cessation practice. In this study it was important to use methods that capture and make explicit the process and assumptions shaping the smoking cessation groups.
Research sample Data were firstly collected by observing a snapshot of 12 existing smoking cessations groups in a lowincome community in Scotland over a six-week period, from October to December 2003. Secondly, five debriefing sessions were held with the group facilitator to unpack the assumptions behind the approach. Thirdly, 11 interviewees were selected purposively out of a total group sample of 67, in order to assess their perceptions and the impact of the groups on their smoking. These 11 interviewees had made use of the service at least three times within six consecutive months, namely between June and December 2003. At the same time as this process evaluation was conducted, the NHS commissioned a study that surveyed a sample of 114 clients who used the ‘Smokey Joe’ service in 2003.30
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Ethical approval was provided by the local NHS ethics committee, as the participants were patients of existing services. Consent was obtained from all smoking cessation group members, as the researcher observed the group. To ensure confidentiality, participant names have been replaced with pseudonyms.
Impact evaluation—individual interviews
Process evaluation: group observations
Data analysis
Participants were from existing smoking cessation groups located in the Health Centre. On average these groups consisted of 11 clients, with the largest group comprising 19 and the smallest two. Over the six-week period 67 different clients made use of the smoking cessation groups, 49 of whom were female and 18 male. Clients ranged in age between 20 and 77 years, with the majority being between 30 and 69 years of age. By cross-referencing client postcode information with data from the ‘‘Scottish indices of 2003’’ data zones, we can see in Table 1 that clients came from data zones that fall into the Scottish index of multiple deprivation (SIMD) deciles 2–10. Splitting the deciles into the five most deprived (deciles 1–5) and most advantaged ones (deciles 6–10), respectively, suggests that our sample is fairly evenly distributed between the more deprived and more advantaged zones. Thus, we find 31 clients living within SIMD deciles 1–5, while 29 reside in SIMD deciles 6–10. This mixed social group was surprising as the area of the study is recognized as a lowincome area.
The analysis represents a holistic-content perspective.31 In this case it involved considering the multiple narratives of the smoking cessation groups as both context and content. A number of quality practices were used to develop rigour in this qualitative research. Firstly, the researchers were reflective as both data collectors and analysts, and considered their own values and positions regarding smoking. Secondly, there was a deep immersion in the data that provided the richness of detail ‘‘in the data and the analysis’’.32 The quality of the detail was also enhanced by good transcription, supported by detailed field notes. All group sessions and interviews were transcribed and converted to a format suitable for analysis using the software package QSR N6 (QSR International). Based on the field notes for the group observations and the individual interviews a number of recurrent meta-narratives in relation to the overall group story and process, as well as each individual’s quitting story, were identified. The meta-narratives were used as a framework for more focussed coding to identify sub-narratives
Table 1 The split of group observation clients according to Scottish index of multiple deprivation (SIMD) deciles.
Table 2 Split of postgroup sample according to Scottish index of multiple deprivation (SIMD) deciles.
SIMD deciles
Number of clients per SIMD decile
SIMD deciles
Number of attendees per SIMD
SIMD 1 (most deprived) SIMD 2 SIMD 3 SIMD 4 SIMD 5 SIMD 6 SIMD 7 SIMD 8 SIMD 9 SIMD 10 (most affluent) Total number of clients included Missing data
0 16 6 4 5 12 6 4 0 7 60
SIMD 1 (most deprived) SIMD 2 SIMD 3 SIMD 4 SIMD 5 SIMD 6 SIMD 7 SIMD 8 SIMD 9 SIMD 10 (least deprived) Total number of attendees included Missing data
2 2 1 2 1 0 0 0 0 3 11
7
The 11 interviewees were between 36 and 68 years of age, with an average age of 53, and consisted of nine women and two men. The split of this group sample according to SIMD deciles is shown in Table 2.
0
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within each meta-narrative. Other publications provide a full microanalysis of all these narratives.33 In this paper we focus on the perceived effectiveness of the use of the stories in smoking cessation as well as the value of flexible service delivery.
Perceptions of the service
Results Effectiveness Follow-up of the 11 interviewees indicated that at the time of the interview only two interviewees were smoking, one smoked two cigarettes and the other between 10 and 20 cigarettes a day. Six of the other interviewees had had brief relapses over Christmas and/or New Year, which meant that at the time of the interview they had stopped smoking for between 5 and 7 weeks. The remaining three interviewees had not smoked for 9, 7 and 4 months, respectively. The clients’ original and current smoking behaviour is summarized in Table 3. It should be noted that by selecting attendees who had made use of the service at least three times within six consecutive months, namely between June and December 2003, there is the potential that we selected people with a bias towards a positive outcome. Furthermore, the retrospective monitoring study conducted by GSR (2004) suggested that the monitoring of a sample of 114 clients (40% response rate) who used the ‘Smokey Joe’ service in 2003 indicated a quit rate of 16% and that this quit rate had been sustained at the 12 month follow up,30 however this rate does not represent an intention
Table 3
to quit rate, as within the current monitoring arrangements this was difficult to achieve due to the retrospective design of the monitoring and also the mixed composition of the groups that consisted of smokers deciding to quit, those who have quit and those who have relapsed.
Flexibility Clients valued the friendly, non-judgmental atmosphere and emphasized that this created an open and trusting environment in which they felt comfortable discussing their successes as well as their setbacks. The approach allowed clients to make their own decision when to stop. There is no time scale in which they have to achieve a nonsmoking status, nor is there a time limit for group membership. Clients valued the flexibility of the service which allowed them to make use of it when they could and when they most felt they needed it. Not surprisingly perhaps, the open-ended nature of this service invites clients to regard stopping as a long-term commitment, which may require longterm support. Extract 1: Peter: I said to him [the group facilitator] y I said, when do I get thrown out? I feel a wee bit embarrassed. Maybe I shouldn’t feel embarrassed. I don’t know. But they all say, that’s four weeks and three weeks or two weeks or two days or a day and I go y seventeen weeksy I said when do I get thrown out? Terry said, ye never get thrown out of here, ye can come back and forward as ye like, ye know. So I felt quite
Interviewees’ original and current levels of consumption.
Pseudonym
SIMD decile
Original consumption level
Current consumption level
Number of times attended in 6 months
Group attendance
Gill Muriel Melanie Dan Margaret Fiona Annabelle Peter Anne Rhona Tania
1 1 2 2 3 4 4 5 10 10 10
10–15 a day 40 a day 20 a day 12 cigars a day 11–13 a day 20 a day 30 a day 30 a day 30–40 a day 20 a day 40 a day
2 a day None, quit 9 None, quit 5 None, quit 5 None, quit 7 None, quit 6 10–20 a day None, quit 4 None, quit 7 None, quit 7 None, quit 5
3 4 5 3 8 4 4 3 9 4 3
Yes One-to-one Yes Yes Yes Yes No Yes Yes Yes Yes
Scottish index of multiple deprivation, SIMD.
months ago weeks ago weeks ago weeks ago weeks ago months ago months ago weeks ago weeks ago
ARTICLE IN PRESS 346 happy at that, ye know. He said, you just keep coming son, you just keep coming. Client need for long-term support can also be seen in the extract below in which the interviewee talks about how they intend to make use of the service in the future. Extract 2: Dan: y I don’t think I’ll be one of these people that maybe come for three months. And then say I don’t need to go there any more. I see this as a long-term thing. And I will continue coming for as long as possible. Mixed groups—smokers at different stages An important reason why the group seems to work so well as a source of support for clients lies in the fact that the groups are mixed, i.e., that long-term attendees and newcomers, as well as people who are still smoking and those who have stopped are all in the same group. Interviewees described people who have given up smoking, yet continue coming to the group, as providing them with motivation to stop, or as a kind of ‘positive’ template that they were aiming to emulate when they first started going to the group. Extract 3: Rhona: I think it’s quite good that the group’s quite varied. y So it’s quite good to see people that were succeeding and that kind of thingy if it was a sort of y these classes start this date and end that date. I don’t think that would be very good. I think the fact that they are kinda mixed up and ongoing is betteryBut if you said, oh you have to go to the anti-smoking class this week and it lasts for 6 weeks and everybody was at the same stage, I don’t think it’d be the same. I think it’s quite good to see people at all different kinda stages. Using stories Stories and metaphors are used in the groups as vehicles for change. Story telling is a common way of gaining attention and interest. The language used and the types of stories told reflect the context of the local culture. Engaging group members in each other’s stories about smoking and stories of quitting smoking are an important part of the change process. This becomes clear in the following extract from one of the debriefing sessions with the group facilitator. Extract 4: Researcher: y story telling is not just about the story. It’s about the person who tells the story as well and the manner in which the story’s told. So
D. Ritchie et al. first of all, I was wanting to ask you a bit about that. What do you think are the functions of the stories that you tell yourself, you know, what are you trying to do when you’re telling stories, as you do? And the other thing is what do you think is the function of getting the participants to tell their own stories? Group facilitator: The reason I’m telling a story is its communication. Straight into the person’s mind that breaks down barriers. So in other words, if you gave a lecture by giving the facts about smoking, just hard numbers, 320 people die every day and so on and so forthy. Within seconds, within milliseconds with some clients, they will switch off and not hear anything because their mind will wander onto everyday thingsyNow if you start to tell a story and if you think for instance where, say you start to tell a personal story about something you did on a night out or someone else has done on a night outy so you don’t stop there, I need to know more, I want more. And when you are telling a story, the client is hanging on every word, processing and understanding every word that’s going onyAnd they will listen right to the last full stop because they want to know the ending. So in terms of getting information across to assist a client to do whatever they want to do, it’s definitely a great mediumySo that’s what we’re doing here with the story because stories are patterns, so it’s expected y they almost know before they go to the pub the story of that pub. So you’ve got to run with itySo that they recognize their own part as an actorySo we’re talking in here in terms of factual information and just giving facts doesn’t do the job but about trying to kind of embrace and engage in people’s stories is the kind of thing that people recognise and, you know, as something that they would normally do in their own lives, particularly anything that would have engaged them anyway. Equally the participants in the group valued the way story enables them to engage with the process. And the participation and engagement with each other’s stories sustained them in their quit attempt. Extract 5: Margaret: y I will go down because I think people want to hear. Hear how you’re doing and you want to hear how everybody else is doing. You want to see how everybody’s getting on. y I think you quite look forward to coming down and hearing all the stories.
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Discussion
Acknowledgements
The case study, although limited to one context, has offered the opportunity to respond to calls for qualitative case studies to be undertaken to provide process-based evaluations of practice. It aimed to make explicit the assumptions shaping the practice of smoking cessation groups using the medium of the story and assessed the smokers’ perceptions of the value of the new method in their attempts to quit smoking. The findings do provide approaches that may overcome the limitations of the current smoking cessation methods, particularly the limitations in contextualizing local cultures and influences on smoking other than behaviour. Firstly, this case study demonstrates an approach that incorporates the context, culture and realities of people’s lives, and stories are used to both locate the process of change within people’s daily lives as well as to enable people to engage in a supportive process with others. Secondly, the intention to change is perceived by many smokers to be unstable and requires opportunities for longerterm support. Flexibility in their attendance and ongoing support to both make the decision to stop and stay stopped is clearly valued by the participants and supports the findings from the English studies for the need for flexibility in smoking cessation in deprived areas.22,23 It should be noted, however, that the actual membership of the smoking cessation groups when analysed by postcode did find a surprising social mix with higher income attendees than expected in a low-income area. Thirdly, including people at the different stages of change seems to be positive and the participants appear to incorporate without difficulty those who are still smoking with those who have stopped. Many find the insights of those at the different stages very valuable in their own quit attempts. In summary the hypotheses generated by the work suggest that the ‘one size fits all’ approach of current practice is not always valued by all smokers, and flexible services that offer support to a range of smokers are as beneficial in terms of quit rates as the more ‘traditional’ structured and standardized programmes. In addition, programmes that are tailored to the individual’s context and culture, as well as the individual’s personal life situation through the medium of the story, are valued and acceptable to the participants. Further research is required in a range of contexts to test these hypotheses. New methods are needed for those who do not benefit from the more structured programmes.
‘Smokey Joe’ is one of 11 local pilot projects funded through Partnership Action on Tobacco and Health, part of ASH Scotland.
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