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Looking Inside the Black Box: Using Intervention Mapping to Describe the Development of the Automated Smoking Cessation Intervention ‘Happy Ending’

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The digital therapy intervention for smoking cessation, ‘Happy Ending’, has been shown to be efficacious in two previous randomised controlled trials. The aim of the current article is to disentangle the rationale of the intervention and describe its development. For this purpose, Intervention Mapping is used as a descriptive tool. The intervention is fully automated and delivered by means of the Internet and mobile phones. It is based on self-regulation theory, social cognitive theory, cognitive-behaviour therapy, motivational interviewing and relapse prevention. The ordering of the content is based on a reasoned chronology, modelled according to psychological processes that people experience at certain time points in a process of therapy-supported self-regulation. The design of the intervention is innovative in that it combines four media channels (SMS, IVR, e-mail, and web), and in the combination of just-in-time therapy and a tunnelling strategy based on the natural chronology of quitting. The two forms of just-in-time therapy are a craving helpline (mainly targeting negative affect), and the provision of relapse therapy based on a daily assessment of the target behaviour. The present article meets the recent calls for more thorough descriptions of interventions, and may inform systematic reviews and the development of interventions.
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29
Brendryen, H., Kraft, P. & Schaalma H., (2010). Looking inside the black box: Using intervention mapping to describe the development of the
automated smoking cessation intervention happy ending.
Journal of Smoking Cessation, 5
(1), 29–56. DOI 10.1375/jsc.5.1.29
Address for correspondence: Håvar Brendryen, Norwegian Centre for Addiction Research, Kirkeveien 166, 0407 Oslo, Norway. E-mail:
havar.brendryen@medisin.uio.no
Information and Communication Technology (ICT; e.g.,
the internet, computers and mobile phones) provide a
technological platform for behavioural interventions
with great potential. This is due to the high reach and
low cost associated with a mass media approach, and the
inherent interactivity of ICT not found in other mass
media. An increasing number of trials of ICT-based
interventions for smoking cessation demonstrate the
viability and efficacy of such interventions (An et al.,
2008; Brendryen, Drozd, & Kraft, 2008; Brendryen &
Kraft, 2008; Muñoz, Perez, & Bansod, 2004; Rodgers et
a1., 2005; Strecher 1999; Strecher, Shiffman, & West,
2005; Swartz, Noell, Schroeder, & Ary, 2006; Walters,
Wright, & Shegog, 2006) Insufficient reporting of the
interventions, however, is a general weakness within this
body of literature (Dombrovski, Sniehotta, Avenell, &
Coyne, 2007; Gutmann et al., 2004; Michie & Abraham,
2008; Schaalma & Kok, 2009; Strecher, 1999, 2008;
Walters et al., 2006) hampering the progress of the field.
Although the interventions may be effective, they appear
as a ‘black box’ for practitioners and the scientific com-
munity — it remains unclear as to why and how they
work (Dombrowski et al., 2007; Michie & Abraham
2008; Strecher 2008) A set of comprehensively and
adequately described interventions, in combination with
effect studies and other evaluative research, will provide
Looking Inside the Black Box:
Using Intervention Mapping to Describe
the Development of the Automated Smoking
Cessation Intervention ‘Happy Ending’
Håvar Brendryen,¹ Pål Kraft,¹ and Herman Schaalma²
1Department of Psychology, University of Oslo, Norway
2Department of Work and Social Psychology, Maastricht University, The Netherlands
The digital therapy intervention for smoking cessation, ‘Happy Ending’, has been shown to be effica-
cious in two previous randomised controlled trials. The aim of the current article is to disentangle
the rationale of the intervention and describe its development. For this purpose, Intervention Mapping
is used as a descriptive tool. The intervention is fully automated and delivered by means of the
Internet and mobile phones. It is based on self-regulation theory, social cognitive theory, cognitive–
behaviour therapy, motivational interviewing and relapse prevention. The ordering of the content is
based on a reasoned chronology, modelled according to psychological processes that people experi-
ence at certain time points in a process of therapy-supported self-regulation. The design of the
intervention is innovative in that it combines four media channels (SMS, IVR, e-mail, and web), and in
the combination of just-in-time therapy and a tunnelling strategy based on the natural chronology of
quitting. The two forms of just-in-time therapy are a craving helpline (mainly targeting negative affect),
and the provision of relapse therapy based on a daily assessment of the target behaviour. The present
article meets the recent calls for more thorough descriptions of interventions, and may inform system-
atic reviews and the development of interventions.
Keywords: intervention mapping, smoking cessation, internet intervention, cell-phone
ARTICLE AVAILABLE ONLINE
Journal of Smoking Cessation
a firm ground on which to develop the practice, to
design new interventions and ultimately to advance the
theories of behaviour change.
Intervention designers approach theory in a way that
is fundamentally different from that of the scientists that
are primarily concerned with generating theory or with
testing a single theory. Intervention designers need to be
able to confront a problem and bring to it multiple theo-
retical and experiential perspectives, rather than define a
practice or research agenda around one theoretical
approach (Bartholomew, Parcel, Kok, & Gottlieb, 1998).
For intervention designers, an intervention is more than
the end product: it is a painstakingly complex and labori-
ous process, requiring a multitude of decisions to be made
along the way — far more than deciding on a set of
behaviour change techniques. Each decision shapes how
the intervention influences its users. Hence, the rationale
for each decision represents valuable knowledge for the
scientific community and intervention designers and
should consequently be reported. Given the large scale of
decisions necessarily involved in designing a complex
intervention, we believe that a certain standardisation of
intervention descriptions will be beneficial, first, because a
standard or a manualised approach will help authors in
writing out all relevant aspects of the intervention devel-
opment process; second, because standardisation will ease
the reading of reports and facilitate systematic review.
In this regard, the Intervention Mapping (IM) proto-
col (Bartholomew et al., 2006) provides a highly
structured approach in describing an intervention
program and its development. IM is a systematic process
to develop health promotion interventions based on
theory, empirical evidence and additional research. IM is
composed of six iterative steps. Each step comprises
several tasks that result in a clear end product, which
again provides a foundation for the next task and the
next step. In this way IM provides intervention designers
with a logical, methodological, step-by-step process that
helps them organise their thinking as they move from
problem to solution, and from theory to practice.
This article describes the development of ‘Happy
Ending’, a digital therapy intervention for smoking cessa-
tion that has been shown to be efficacious in two previous
clinical trials (Brendryen & Kraft, 2008; Brendryen et al.,
2008). The aim of this article is to disentangle the rationale
of the intervention and its development. For this purpose,
the IM protocol is used as a descriptive tool and the six IM
steps provide the structure of the current article. In Step 1 a
needs assessment is presented. In Step 2, the desired behav-
iours that would alleviate the health problem are described.
The result of Step 2 is a set of change objectives describing
what the participants in the intervention program need to
learn or change to accomplish the desired behaviour
change. Step 3 links these change objectives to practical
intervention materials and activities (‘strategies’) via
theory-based behaviour change techniques (‘methods’).
The result of Step 4 is the intervention program itself. Step
5 in the IM protocol is concerned with the adoption and
implementation of the intervention, while the final step is
about planning the evaluation of the intervention.
To provide some preconception of the end product, a
condensed description of the Happy Ending program
follows. The program is based on self-regulation theory
(Baumeister & Vohs, 2004), social cognitive theory
(Bandura, 1997), cognitive–behaviour therapy (Curven,
Palmer, & Ruddell, 2006), motivational interviewing
(Miller & Rollnick, 1991) and relapse prevention
(Marlatt, 1985). One of the core ideas of the program is
to provide the right support at the right time. For
example, the ordering of the content is based on a rea-
soned chronology, modelled according to psychological
processes that people experience at certain time points
in a process of therapy-supported self-regulation (Kraft,
Drozd & Olsen, 2009; Piasecki, Fiore, McCarthy, &
Baker, 2002; Rothman, Baldwin, & Hertel, 2004). The
intervention is fully automated and delivered by means
of mobile phone and the Internet, consisting of:
a 2-week preparation phase, a high-intensity active
quit phase (1 month), followed by a low-intensity
follow-up period (11 months)
more than 400 contacts by e-mail, web-pages,
Interactive Voice Response (IVR) and Short Message
Service (SMS) technology
tunnelled (Danaher, McKay, & Seeley, 2005) and
highly interactive messages
both proactive and reactive components
an interactive quit diary
a craving helpline mainly targeting negative affect
(Kenford et al., 2002; Shiffman & Waters, 2004) and a
combined lapse detection and relapse prevention
system.
The last two components are examples of just-in-time
therapy (Shiffman, 2006).
IM Step 1: Needs Assessment
In Norway, 21% of adult men and 23% of adult females
are daily smokers. Additionally, 10% of both genders
smoke occasionally (Statistics Norway, 2008b). The
smoking prevalence has been steadily decreasing by
approximately 1% each year since 1996 (Norwegian
Directorate of Health, 2007a). It is estimated that 16% of
the per annum deaths in Norway can be attributed to
tobacco smoking and that, for each death, on average 11
years of lifetime is lost (Vollset, Selmer, Tverdal, &
Gjessing, 2006). Hence, reducing the number of smokers
is crucial to the public’s health.
Socioeconomic status (SES) plays a significant role in
smoking and smoking cessation. Low SES groups show a
higher smoking prevalence, have a higher cigarette con-
sumption per day, lower age of smoking onset, tend to
smoke more dangerous products (e.g., roll your own)
30 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
and have a lower quit rate compared to smokers from
high SES groups (Jha et al., 2006; Lund & Lund, 2005;
Lund, Lund, & Rise, 2005). Given the political target of
addressing health inequalities in the population
(Norwegian Ministry of Health and Care Services, 2007),
it is important to develop interventions that are equally
effective for low SES groups.
A substantial proportion (45%) of daily smokers
intend to quit smoking; that is, 13% report that they
intend to quit within the next month and an additional
32% intend to quit within 6 months. However, only a
minority of those with quitting intentions actually initi-
ates a serious quit attempt within that timeframe; only
27% of the daily smokers report a smoking cessation
attempt within the last year. We do not have a reliable
estimate of how many of these actually succeed in
achieving long-term abstinence, but we know that only
18% of the population reports current abstinence and
previous everyday smoking (i.e., 18% refers to the total
cessation rate, accumulated over the years). It should
also be noted that eight out of ten current everyday
smokers have — unsuccessfully — tried to quit smoking
at least once (Norwegian Directorate of Health, 2007a).
Moreover, it has been estimated that only 3–5% of those
quitting without any form of cessation aids succeeds in
achieving long-term abstinence (Hughes, Keely & Naud,
2004). Clearly, there is a gap between motivation and
good intentions on the one hand and successful quitting
on the other, and it seems that for many smokers voli-
tion is the main problem, rather than motivation. The
problem of volition is twofold; smokers with quit inten-
tions (inclined abstainers) usually fail to initiate a
cessation attempt, and quitters usually fail to maintain
abstinence in the long term. Consequently, interventions
are warranted that support the initiation of behaviour
change as well as the maintenance of behaviour change.
Considering the large health load from tobacco use,
the discrepancy between motivation to quit and success-
ful cessation attempts, and the low utilisation of
cessation aids, it seems reasonable to conclude that there
is need for new smoking cessation interventions. Such
programs should support the self-regulatory task of
quitting smoking, including the initiation of the attempt
and the long-term maintenance of abstinence.
Aids to smoking cessation with a documented effect
(Fiore, Jaén, & Baker, 2008) are underutilised (Coccinides,
Ward, Jemal, & Thun, 2005; Norwegian Directorate of
Health, 2007a). Roughly one out of five use such aids, and
medication therapies are far more frequently used than
psychological therapies. A German study found that the
main reasons for nonuse of smoking cessation aids are
being overly self-confident and the perception that the aids
are not helpful (Gross et al., 2008), However, a significant
proportion of smokers also reported cost concerns, embar-
rassment and social stigma as barriers for using cessation
aids. Interventions are justified that support the develop-
ment of a realistic outlook on quitting efforts, that encour-
age using and providing information on relevant aids, and
that protect privacy and anonymity. Another problem is
that the effective psychosocial treatments are relatively
expensive and time-consuming since they require well-
trained counsellors (Fiore et al., 2008). Hence,
interventions with a potential for mass distribution (i.e.,
that can be disseminated to a large target group for a rela-
tively low cost), and that are acceptable to use for a
substantial proportion of persons in the target group, are
warranted. Interventions based on digital media may serve
this purpose (Brug, Campbell, & van Assema, 1999;
Griffiths, Lindenmeyer, Powell, Lowe, & Thorogood, 2006;
Murray, 2008; Tate & Zabinski, 2004; Walters et al., 2006)
Based on the above considerations, a decision to develop a
digital smoking cessation intervention was taken. Note
that, according to the IM-protocol, decisions with regard to
delivery channels should be taken in step four (program
planning). This deviation reflects the fact that, in the
current article, IM was used as a descriptive tool, rather
than a planning tool.
IM Step 2: Matrices of Change Objectives
The second step in Intervention Mapping is about speci-
fying behaviour change objectives. In order to be able to
get to these objectives, IM suggests a procedure in which
general goals (i.e., smoking cessation) are broken down
into goals for subbehaviours (performance objectives),
and correlates of subbehaviours are identified (determi-
nants). Change objectives target the correlates of the
performance objectives.
Task 2.1: Stating Health Promoting Behaviours
The goal of the program was to increase the proportion
of successful smoking cessation attempts (i.e., initiate
and maintain the cessation) among smokers already
motivated to quit. This was to be attained by supporting
and guiding the smokers through the self-regulatory
process of discontinuing their smoking behaviour. To
stop smoking, however, is an incomplete description of
the desired behaviour, and needs to be more closely
described. To do so, we need to consider some basic facts
about the self-regulation of ending addictive behaviours.
Task 2.2: Specifying Performance Objectives
Theories on self-regulation (Baumeister, Heatherton, &
Tice, 1994; Baumeister & Vohs, 2004; Carver & Scheier
1998) enabled the identification of subbehaviours (per-
formance objectives) of the general goal of smoking
cessation. In a broad sense, self-regulation refers to any
effort to alter one’s own responses (including actions,
thoughts, feelings, and desires); that is, to override
impulses. A rudimentary form of self-regulation is self-
stopping. Without regulation, a person would respond
to a situation according to habit, previous learning
history, or innate tendencies and biological needs. Self-
regulation can be divided into three subprocesses: (1)
31
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
self-observation, (2) self-evaluation and (3) self-reac-
tion. Consequently, all these three subprocesses are
represented in the performance objectives (see Table 1).
Self-observation, or self-monitoring, refers to conscious
efforts to explicitly identify one’s own impulses. For
example, observing that: ‘I felt bad; then I thought that a
smoke would cheer me up, and lighted up’. It is important
to not only register behaviour, but also observe the
thoughts and feelings that may precede a craving episode
or a cigarette (e.g., ‘the unresolved dispute with my spouse
made me feel bad’). In addition to negative affect (Kenford
et al., 2002), environmental factors also play a role in elicit-
ing craving (Shiffman et al., 1996). Hence, such factors and
their role in eliciting craving should be a part of the self-
observation process (e.g., ‘when I go to that pub, or meet
persons A, B or C, I usually end up smoking’).
Self-evaluation involves using criteria or standards to
assess the situation, problem or behaviour, that is,
judging how one is doing according to personal goals
(e.g., ‘what does this lapse mean to my quit attempt?’ or
‘will it influence my quit attempt negatively if I do so
and so, or go there and there?’).
Self-reaction is a response to self-evaluation. Self-
reaction refers to any active effort to alter an unwanted
impulse and includes self-stopping, making specific
plans (e.g., action plans and coping plans; Sniehotta,
Schwarzer, Scholz, & Schüz, 2005), and giving oneself
rewards or punishments (Prochaska & DiClemente,
1983). For example: ‘that lapse was a grave mistake, I
must pull myself together, focus on the gains of absti-
nence, and say no the next time someone offers me a
cigarette’. Throughout the course of behaviour change,
these three subprocesses take place in an ongoing circu-
lar process and are equally important. The content of the
processes, however, may change as the person moves
from preparation and implementation to action and
maintenance of the new behavioural pattern.
While self-observation and self-evaluation directly
translate into performance objective #1 (see Table 1), self-
reaction needs further specification. In defining the
performance objectives related to self-reaction, a few
basic facts about smoking cessation and relapse were of
particular importance. First, in spite of being motivated
to quit, many people fail to initiate a cessation attempt,
that is, they remain inclined abstainers (Orbell &
Sheeran, 1998). To reduce the rate of inclined abstainers,
it is necessary to prepare the smokers for the quit attempt
by intervening in advance. Preparing the quit attempt
may increase the likelihood of performing the initial
response. Hence, preparing and implementing is a useful
concretisation of desired performance. Second, a lapse or
a relapse seems to be the rule rather than the exception
— this is true for unaided quitters (Hughes et al., 2004),
as well as for those receiving the most effective treatments
(Lancaster & Stead, 2004, 2005b; Rice & Stead 2004;
Stead & Lancaster 2005; Silagy, Lancaster, Stead, Mant, &
Fowler, 2004; Stead, Perera, & Lancaster, 2006). The risk
of relapse is not over in a few days, but remains high for
several weeks and months. As time goes by, the risk for
relapse gradually stabilises at a relatively low level
(Hughes et al., 2004; Hughes, Peters, & Naud, 2008).
Given the continued and serious risk of relapse,
endurance in the self-regulatory efforts for behaviour
change seems crucial for success. Hence, the quitters need
to uphold the quit attempt over time and to avoid a full-
blown relapse. Coping adaptively with craving is one
specification of this objective. Third, one or more lapses
increase the risk of a full-blown relapse (Ockene et al.,
2000); and among those who experience a first lapse, a
subsequent lapse or relapse is very likely to occur, often
within 4 days (Brandon, Tiffany, Obremski, & Baker,
1990; Shiffman et al., 1996). Fourth, in most cases, a full-
blown relapse is preceded by one or more lapses. Relapses
typically follow a pattern of intermittent episodes of
smoking rather than having a clean start (Ockene et al.,
2000), implying that most quitters do not give up their
quit attempt immediately after the first lapse. In terms of
performance objectives, this translates into resuming the
quit attempt even after initial setbacks (lapses). It should
be noted that formulation of this last performance objec-
tive sparked the idea of intervening at this stage in the
quitting process just-in-time, that is, to intervene as soon
as possible after the lapse (Shiffman, 2006).
To sum up the performance objectives related to self-
reaction, after initiating the quit attempt, the primary
objective is to uphold the quit attempt (i.e., continued
effort). In upholding the quit attempt, two subbehaviours
are particularly important: to cope adaptively with craving
and to resume the quit attempt after a lapse (see Table 1).
Note that for the self-reaction objectives to be reached, a
certain balance between them and self-observation/self-
evaluation (performance objective #1) is necessary.
Task 2.3: Specifying the Determinants
Awareness (knowledge) of the negative health effects of
smoking and of his or her own psychological profile as a
smoker and so forth is probably the first prerequisite of
smoking cessation (Prochaska & DiClemente, 1983).
According to the theory of planned behaviour (TPB)
32 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
Table 1
Performance Objectives for the Self-Regulation of Smoking Cessation
1. Continue self-observation and self-evaluation of smoking behavior,
craving and the actions taken
2. Prepare and implement the quit attempt
3. Uphold the quit attempt over time (avoid relapse)
a. Cope adaptively with craving
b. Resume the quit attempt after a lapse
Note: The aim was to develop an intervention program that supported the self-regulatory
process of smoking cessation through preparation, implementation and mainte-
nance. There is no general chronology among the performance objectives, except
that #2 precedes #3. Objective #1 extends the entire behaviour change process.
(Ajzen, 1991) three types of subjective beliefs determines
intention formation and behaviour; (1) behavioural beliefs
(attitudes), which are beliefs about the specific outcomes
of a behaviour and evaluation of the outcomes; (2) nor-
mative beliefs (norm), which are beliefs about how
significant others thinks and evaluate a specific behav-
iour; and (3) control beliefs (self-efficacy; Bandura, 1997),
which are beliefs about how easy or difficult it will be to
perform a particular behaviour. In addition to these core
TPB variables, research has shown that action planning
and coping planning (planning) are important constructs
to explain why intentions transform into behaviour or
not (Gollwitzer, 1999; Sniehotta et al., 2005). Skills and
behaviour was identified as the final determinant. This
category includes stimulus control (Prochaska &
DiClemente, 1983) and emotion regulation skills (Gross,
2007; Kenford et al., 2002). In sum, six general determi-
nants for smoking cessation and behaviour change were
identified —knowledge, attitudes, norms, self-efficacy,
plans, and finally skills and behaviour. In Task 2.4 of the
IM process, these determinants are to be linked to the
subbehaviours of smoking cessation (see Table 2), based
on a further review of the behaviour change literature and
studies of smoking cessation.
Task 2.4 : Developing a Matrix of Proximal Program Objectives
In reviewing the literature on smoking cessation and
behaviour change, it became apparent that the relevance
of the determinants varies greatly over time. The deter-
minants and processes that guide people’s behavioural
decisions are probably not invariant throughout the
behavioural change process, that is, there is a chronology
to behaviour change and to smoking cessation (Kraft et
al., 2009). First, the process of behaviour change may
consist of distinct phases (e.g., initiation, continued
response, maintenance and habit), in which the chal-
lenges and choices the smoker faces, differ (Rothman,
2000; Rothman et al., 2004; Prochaska & DiClemente,
1983). Second, the variables that influence smoking
relapse may each make time-shifted contributions to
relapse risk, and in this regard Piasecki’s model of relapse
proneness was informative (Piasecki et al., 2002). The
smoking cessation chronology may consist of processes
that are common for all quitters, as well as an idiosyn-
cratic residual of processes unique to individuals — both
being important to consider for intervention purposes.
To stop smoking can be seen as a process in which the
quitter is continually faced with decisions relevant to the
outcome of the process. The decision criteria, however,
may be differential over time, rather than continuous. To
take the most obvious example, the decision criteria that
lead people to initiate a change in behaviour are different
from those that cause them to maintain the new behav-
iour (Rothman et al., 2004). The decision to initiate a
cessation attempt depends on whether a person is
holding favourable expectations regarding future out-
comes of being abstinent. At this stage, these expectations
are typically tied to the long-term positive outcomes of
becoming abstinent, like good health, living to see one’s
children/grandchildren grow up, maintaining good looks,
and so on.
The decisions regarding maintenance of abstinence,
however, involve considerations of the experiences
people have had engaging in the new behavioural
pattern. In this way, maintenance decisions reflect an
ongoing assessment of the behavioural, psychological
and physiological experiences afforded by the behaviour
change process. Put differently, the abstainer will main-
tain abstinence only if the experiences of the new
behaviour is sufficiently desirable to warrant continued
action (Rothman et al., 2004). Examples of such short-
term positive outcomes are the praise from spouse, peers
or family (Park et al., 2004); improved breath, better
lung capacity, improved stamina during physical activity,
improved smell/taste and so forth. In short, all processes
of physiological restoration can be used as examples of
short-term positive outcomes of abstinence (Bize et al.,
2005). Conversely, examples of negative short-term out-
comes of newly gained abstinence include negative affect
(Kenford et al., 2002), weight gain (Parsons et al., 2009),
and all of the common withdrawal symptoms (craving,
irritability, anxiety, restlessness, insomnia, and concen-
tration difficulties) (Piasecki, 2006).
The problem for most early abstainers, however, is
that the negative short-term consequences of stopping
smoking are more pressing and tangible, compared to
both the reasons for quitting in the first place (i.e., long-
term positive outcomes of abstinence) and the early
gains of abstinence as experienced postcessation (i.e., the
short-term positive consequences of abstinence). As a
consequence, the negative short-term consequences of
abstinence tend to outweigh the positive consequences
in the decision process (as should be evident from the
high rate of relapse) (Rothman et al., 2004). Therefore, a
heightened awareness of the positive short-term conse-
quences of early abstinence might be an important
determinant for avoiding relapse. Such awareness may
be raised simply by providing information about the
health benefits of abstinence and the like. However,
while the level of carbon monoxide in the blood will
return to normal levels within a day (Kambam, Chen, &
Hyman, 1986), the pulmonary function, however,
requires approximately 8 weeks of abstinence from
smoking in order to return to the levels of nonsmokers
(Mitchell, Garrahy, & Peake, 1982). Hence, to increase
the perceived personal relevance of the messages and
hence the persuasive effect, it is better to inform abstain-
ers about the benefits of lowered levels of carbon
monoxide around the first abstinence day and the bene-
fits of pulmonary function after some weeks, and not
vice versa. Similarly, other health benefits are tied to par-
ticular time frames. In other words, we suggest that there
33
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
34 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
Table 2
Proximal Program Objectives
Determinants
Performance objectives Knowledge Attitudes Norms Self-efficacy Plans Skills and behaviour
Note: The left column contains the performance objectives, while the determinants are entered across the top of the matrix. The intersecting cells contain program objectives (either learning objectives or change objectives), describing what the participants in the intervention
program need to learn or change (related to the determinant) to accomplish each performance objective.
1. Continued
self-observation and
self-evaluation
2. Prepare and implement
the quit attempt
3. Uphold the quit attempt
over time
3a. Cope adaptively with
craving
3b. Resume the quit attempt
after a lapse
Recognise need for sustained
effort, self-observation and
self-evaluation; Know their
own psychological profile as
a smoker; Know the structure
and the ways of the program
Can explain the smoking
cessation process (e.g., the
importance of preparation,
craving, challenges, lapse,
relapse, available help from
program, medication, etc.)
Awareness of the sustained
risk for relapse
Awareness of own
vulnerability and what
elicit/precedes craving
Know the psychological
consequences of having a
lapse and distinguish between
a lapse and a relapse
Express confidence in
treatment provider and sense
of therapeutic alliance; Active
involvement in own quit
attempt
Positive outcome
expectancies
Maintain decisional balance:
the short-term positive
consequences of quitting and
the negative consequences of
starting to smoke again
Subscribe the value of using
tools and aids for smoking
cessation
Attribute failures externally
and achievements internally
Define realistic personal
standards; Have insight into
the extent that one’s smoking
deviates from one’s norm
of perceived personal
responsibility of health
Recognise responsibility for
quitting on the predefined
date
Recognise responsibility for
sustained effort; Activate
(normative) support from the
environment
Recognise responsibility for
adaptive coping
Recognise that starting to
smoke again after a lapse is
a deliberate choice — not
something that became
inevitable after the lapse
Precessation self-efficacy
Implementation self-efficacy;
Coping self-efficacy
Maintenance self-efficacy
Coping self-efficacy
Recovery self-efficacy;
Focusing on what is achieved
rather than failure
Plan to self-observe and
self-evaluate
Develop a set of action and
coping plans prior to quit
attempt (related to craving
and high risk situations);
Plan how and when to reward
oneself for achievements
Continue to plan how and
when to reward oneself for
achievements
Refine the set of action and
coping plans mentioned
above
Make an action plan,
immediately after a lapse,
about being abstinent from
the next morning on
Active participation in
program; Be able to detect
smoking urges and cravings
early
Eliminate smoking cues in
personal environment just
prior to quit attempt;
Implement self-rewards
Adhere to the intervention
program; Implement
self-rewards
Implement selected coping
plans during craving
episodes; Emotion-regulation
skills
is a window of relevance for such health information,
and that the degree to which a particular health message
about the benefits of abstinence is persuasive will
depend on the time point of delivery. Therefore, the time
point for delivery should be as close to the actual physio-
logical change as possible.
Similarly, but perhaps not so importantly, a heightened
awareness of the negative consequences of starting to
smoke again might help prevent a relapse. Smokers
seeking treatment are probably aware of many of the nega-
tive health outcomes of smoking; hence, the further
provision of such health information will probably have, at
best, a very small effect. Providing them with negative
information about the tobacco industry, however, might
have a better relapse prevention effect (assuming that such
information is not so well known). Planning and initiating
self-rewards for the achievements made throughout the
quit attempt also adds positively to decisional balance
(Prochaska & DiClemente, 1983; Thoresen & Mahoney,
1974). Note that making plans for self-reward is cate-
gorised under planning together with action and
coping-plans in Table 2, despite the difference between
these concepts.
Negative affect, stress and bad mood in particular,
seem to play a very important role in smoking lapse and
relapse (Kenford et al., 2002). Lapses are not predomi-
nantly promoted by slow oscillations in background stress
or negative affect in the days leading up to the lapse.
Instead, precipitous spikes in negative affect in the
minutes rather than the hours leading up to the lapse
were particularly important in the process leading to a
relapse (Shiffman & Waters, 2004). Taken together, this
suggests that interventions would benefit from including
elements that effectively help quitters to tackle the experi-
ence of negative affect, either to teach quitters cognitive or
behavioural skills to handle such surges of negative affect
in advance, or by providing quitters with tools that can be
used when needed (e.g., just-in-time therapy) (Shiffman,
2006). Inviting quitters to make plans for coping with
craving surges is another promising strategy (Brendryen
et al., 2008; Sniehotta et al., 2005; van Osch et al., 2008).
Self-efficacy plays an important role in smoking ces-
sation (Marlatt, Baer, & Quigley, 1995; Gwaltney et al.,
2002, 2009) and is probably phase-specific within a self-
regulatory cycle (Marlatt et al, 1995; Luszczynska &
Schwarzer, 2003; Schwarzer & Renner, 2000). In this
regard, distinguishing between action self-efficacy,
coping self-efficacy and recovery self-efficacy has been
suggested (Marlatt et al., 1995). For example, some
smokers may have a high confidence in their ability to
initiate a cessation attempt (action self-efficacy), but
little confidence in their ability to maintain abstinence
(coping self-efficacy) and in recovering after a lapse
(recovery self-efficacy). In contrast, other smokers may
have a high confidence in their ability to resist smoking
in tempting situations, but little confidence in initiating
the attempt. Schwarzer and Renner (2000) found empir-
ical support for this distinction.
Another example of the time-shifted importance of
determinants, is how relapse proneness seems to wax and
wane throughout a quit attempt. In this regard, Piasecki
and colleagues (2002, 2003) have provided a tentative
model of relapse proneness. The model describes three
forces of relapse: physical withdrawal, stressors/
temptations and cessation fatigue. The relative contribu-
tion to relapse proneness from each force follows a
chronology, that is, three phases. The withdrawal phase
represents the first days or week(s) of a quit attempt and is
characterised by a peak in symptoms in a majority of quit-
ters. In this phase massive relapse is observed, illustrated by
the fact that only 24–51% of unaided quitters survive as
abstinent through the first week of their quit attempt
(Hughes et al., 2004). The fact that the symptom level is so
high, is so commonly observed and is so often followed by
a full-blown relapse, makes it reasonable to look for a cause
that is common in all quitters. The physiological counter -
reaction caused by declining drug levels in the body seems
to be a promising candidate. Even though it is reasonable
to assume that the effects of the physiological processes
upon relapse proneness in the withdrawal phase, for the
main part, is mediated via psychological processes (Piasecki
et al., 2002).
In the second phase (stressors/temptations), relapses
seem to be related to sudden spikes in relapse proneness,
which appears to last for minutes rather than hours or
days. The sudden spikes in relapse proneness probably
mirror the situational cues that the quitter is confronted
with in his/her environment. These situational cues are
experienced by the quitter as stressors and/or tempta-
tions and they are represented psychologically as
irregular surges in the craving for smoking. Throughout
this phase, the quitter is occupied with facing and fight-
ing a variety of novel situations and temptations to
smoke, and each smoke-free day is probably seen as an
accomplishment (Piasecki et al., 2002).
If the quitter remains abstinent, the time interval
between the sudden spikes in relapse proneness appear
to increase, while the experienced urge to smoke seems
to decrease. With experience, risk situations are proba-
bly seen less as new adventures and more as taxing. At
this stage the quitter enters a period characterised by
the cumulative toll or cost of staying abstinent. When
relapse occurs in this third and final phase of a quit
attempt, fatigue is probably involved. Fatigue is con-
ceived of as a latent construct encompassing loss of
motivation, loss of hope in cessation success, a reduc-
tion in coping attempts, decreased self-efficacy and
exhaustion of limited resources for self-regulation
(Piasecki et al., 2002).
Provided that Piasecki’s model holds water, pharma-
cological aids (like NRT) are particularly important in
the withdrawal phase, psychosocial support focusing on
35
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
mastery of stress and bad mood in the second phase, and
treatments aimed at boosting motivation or other ways
of dealing with fatigue should be of particular impor-
tance in the final stages of a cessation attempt.
Self-determination theory (Deci & Ryan, 1985;
Ryan & Deci, 2000) posits that motivation to perform a
behaviour is varying along a continuum in the extent
to which the regulation of the behaviour is
autonomous, and the degree to which the motivation is
intrinsic. More intrinsic motivation and more
autonomously regulated behaviour are likely to lead to
better performance, better learning, more positive
coping styles (Ryan & Deci, 2000), and both greater
attendance and involvement in addiction treatment
(Ryan, Plant, & O’Malley, 1995). A behavioural goal
that is consciously valued and accepted as personally
important results in self-regulation based on identifica-
tion. Furthermore, in self-determination theory, the
term integrated self-regulation refers to when an iden-
tified regulation is fully assimilated into the self (i.e.,
brought into congruence with one’s other values and
needs). As people identify and integrate regulation,
greater autonomy is the outcome (Ryan & Deci, 2000).
Hence, the forming of a psychological contract in
which smokers consciously value their behaviour goal
may increase chances of successful quitting.
Research on therapy outcome has revealed that general
factors can be every bit as important as the selection of spe-
cific therapeutic methods and techniques (Weinberger,
1996). Such general factors of therapy include a perceived
therapeutic alliance and confidence in the treatment
provider. Hence, establishing such general factors should be
an objective of any intervention program.
Based on the literature review above, the performance
objectives (see Task 2.2 and Table 1) were crossed with the
determinants (see Task 2.3). In Table 2, the performance
objectives were entered in the left column of the matrix,
and the determinants were entered across the top of the
matrix. Then, change objectives were defined for the cells
formed at the intersection between performance objec-
tives and determinants. These change objectives answer
the question: What do the participants in the intervention
program need to learn or change, related to the determi-
nant, in order to accomplish the performance objective?
The resulting matrix of program objectives may be
regarded as the focal point for the integration of theory
with the desired behaviour changes, and for the IM
approach itself (Bartholomew et al., 2006).
IM Step 3: Theory-Based Methods and Practical Strategies
Intervention Mapping Step 3 addresses the selection of
theoretical methods and practical strategies. To facilitate
the selection of theoretical methods, the change objec-
tives were ordered by determinants. Second, selected
methods were translated into practical strategies. Third,
the strategies were matched with the proximal program
objectives to ensure full coverage of the most important
program objectives.
Task 3.1: Selecting Theoretical Methods
Several theories and models of behaviour change served
as the foundation for the development of the current
intervention. Social cognitive theory was useful in speci-
fying four sources of self-efficacy that each provides
specific targets for intervention. The four sources of
self-efficacy are overt mastery experiences, vicarious
experiences, verbal persuasion and physiological arousal
(Bandura, 1997). Additionally, cognitive–behavioural
therapy (Berge & Repål, 2004; Curven et al., 2006) and
the transtheoretical model (Prochaska & DiClemente,
1983) describe several methods of stimulating self-
observation, self-evaluation and self-reaction. These
methods include consciousness raising, giving
psychoeducational information, dramatic relief, self-
reevaluation, environmental reevaluation, decisional
balance, modelling, guided practice, cognitive restruc-
turing, relaxation training, training in problem-solving
skills, reinforcement and feedback (Berge & Repål, 2004;
Curven et al., 2006; Prochaska & DiClemente, 1983).
Inspiration was also drawn from the five basic princi-
ples of motivational interviewing: express empathy,
develop discrepancy, avoid argumentation, roll with
resistance and support self-efficacy (DiClemente, 1991;
Miller & Rollnick, 1991). These principles are important
in building confidence in the treatment provider and in
fostering a perceived therapeutic alliance. In addition to
these general theoretical approaches, more specific
theories suggested a variety of intervention methods
(see Table 3).
Task 3.2: Translating Methods Into Practical Strategies
and Materials
In translating methods into practical strategies, one
needs to consider the feasibility and the practical
context. Hence, this task has to be done in iterative steps
with the next task (developing the actual materials), to
fit the strategies with channels chosen (i.e., the mobile
phone and the Internet). Note that contrary to what is
prescribed in the IM protocol, the decision with regard
to delivery channel was done prior to step four. Table 3
gives an overview of selected theoretical methods, prac-
tical strategies, considerations for use and the theories
from which the methods and strategies are derived.
Considerations for use are the conditions under which
the methods are shown to be effective and are essential
to keep in mind when translating methods into practical
strategies and program components. These considera-
tions can be drawn from either theory, empirical
findings, or could be considerations of what is feasible in
the current practical context. For example, the optimal
time window for delivery is an important aspect of such
considerations, particularly for a tunnelled ICT-based
program. Keep in mind that one method can lead to
36 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
37
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
Table 3
Personal Determinants, Theoretical Methods, Practical Strategies, and Considerations for Use
Personal Theoretical Practical strategy: Considerations for use:
determinant method What should be done? How should it be done?
Knowledge
Attitudes
Norms
Active learning
(ELM, SCT)
Consciousness
raising (TTM)
Dramatic relief
(TTM)
Arguments (TPB)
Operant
conditioning
Self-reinforcement
(SCT)
Reattribution
(Attribution
theory)
Cognitive
restructuring
(CBT)
Visible
expectations (TPB)
Visible
expectations (TPB)
Environmental and
self-reevaluation
(SRT, TTM)
Anticipated regret
(TPB, TTM)
Modelling (SCT)
Resistance to
social pressure
(Social inoculation
theory)
Information given in texts. Cognitive and
behavioural assignments.
Information, guidelines, assignments,
examples and tips to increase self-
awareness. Give some information, then
encourage further search. [Morning call or
SMSs with ‘read more on the web’]
Clients are encouraged to experience
negative emotions (and write down) that
would accompany starting to smoke
again. Diary assignments
Provide client with additional arguments
for staying abstinent. Timing:
postcessation.
Continuously inform clients about the
short-term positive consequences of
quitting (resembling biofeedback).
Encourage self-reinforcement
Teach clients to explain setbacks and
successes in terms of adaptive attributions
Identify and change counterproductive
thoughts. Provide a list of typical counter-
productive thought related to smoking
cessation
Client encouraged to map the
environment for potential supporters.
Stimulate thinking about expectations
from significant others.
Behaviour change plan (MI)
Clients are stimulated to anticipate the
negative affective consequences of starting
to smoke again
Stories of potential role models and how
they coped with difficulties etc.
Clients are encouraged to anticipate
counter arguments
Should be relevant, comprehensible, interesting and rewarding to follow,
vary in format and media, and provided in a friendly tone/atmosphere.
Learning moments should be short and many, rather than few and
lengthy. Important content should be repeated across time, and across
media. Timing: start as early as possible, prior to challenging situations.
Feedback and confrontation should be followed by increase in problem-
solving ability and self-efficacy. Many contacts better than few. Provide
complementary information, with cross-references, in several modes,
may facilitate active processing.
Emotions should be aroused and subsequently relieved. Timing: in a
critical situation, and immediately after a lapse (just-in-time).
New arguments. Clients are probably already aware of the behaviour–
health link; but negative information about tobacco industry may be
novel. This may also foster a sense of alliance. Timing: after cessation day
— otherwise it might result in negative affect.
Important to be aware of the short-term positive consequences of not
smoking, because they represent positive reinforcement of the new
behaviour. Timing is very important, and optimal timing will wary with
the specific information.
The plan should include a concrete reward, a clear criterion for acquiring
the reward, and it should be formed in advance.
Requires unstable and external attributions for failure, and stable and
internal attributions for mastery. Timing: optimistic attribution pattern
should be primed early, and reinforced after lapse (just-in-time).
Changing cognitions about causes and consequences of behaviour
(i.e., craving, the fear of failing etc.)
Positive expectations are available in the environment.
Timing: after cessation day.
Cognitive and emotional change should be reinforced.
Must stimulate imagination. Timing: after lapse (just-in-time therapy).
Model should be reinforced.
Requires building of refusal skills.
several strategies, and likewise, several methods may
become one strategy.
IM Step 4: Program Planning
Step four of IM is the actual design of the program. Task
one in this step involved organising strategies into a deliv-
erable program, for example, determining the program
structure (i.e., scope and sequence), theme and channels
for delivery. Task two concerned the development of the
program material. Finally, the last task was to pretest the
program materials with the target group and implementers
before the final materials were produced.
A design team consisting of researchers, psychologists
and a copywriter/art director planned and developed the
intervention. The team comprised a broad spectrum of
experience, including: advertising and public relations,
web design, production of smoking cessation materials,
smoking cessation counselling and general clinical coun-
selling. Moreover, a computer company, experienced with
making integrated phone and web solutions, provided
valuable input and performed the computer program-
ming. Finally, professional actors were hired to record the
voice materials, while a character model agency provided
pictures that were to be used on the web pages.
Task 4.1: Organise Strategies Into a Deliverable Program
Today, ICT represents a promising channel for dissemi-
nation of behaviour change interventions in Norway.
Most Norwegians have access to, and use, the internet
and mobile phones. The majority (86%) of Norwegians
report using the internet once a week or more (Statistics
Norway, 2008a); 58% report having used the internet for
health purposes (Andreassen, Wangberg, Wynn et al.,
2006). Almost all Norwegians have a mobile phone, and
SMS text-messaging is widespread: on an average day,
61% of all Norwegians send one or more private SMS
text messages (Statistics Norway, 2008c). Hence, the
decision with regard to developing an ICT-based inter-
vention was taken at the very beginning of the process.
Moreover, to facilitate reaching a high number of people
with limited resources, the program was to be fully auto-
mated (Science Panel on Interactive Communication
and Health, 1999). Smoking cessation interventions have
previously been delivered by means of the internet and
e-mail (Lenert et al., 2004; Swartz et al., 2006; Strecher et
al., 2005), SMS (Rodgers et al., 2005) and Interactive
Voice Response (IVR; Ramelson et al., 1999), but these
media had never been used in combination. From the
start of the project, applying a multimedia approach was
38 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
Note: ELM = Elaboration Likelihood Model; SCT = Social Cognitive Theory; SRT = Self-Regulation Theory; TTM =Trans-Theoretical Model; TPB = Theory of Planned Behaviour;
MI = Motivational Interviewing; CBT = Cognitive–Behaviour Therapy; MI = Motivational Interviewing.
Text may refer to both ordinary texts and to texts that are read out loud to the clients (using IVR technology). Timing comments refers to the optimal window of relevance for using
the particular method or strategy.
Table 3 continued
Personal Determinants, Theoretical Methods, Practical Strategies, and Considerations for use
Personal Theoretical Practical strategy: Considerations for use:
determinant method What should be done? How should it be done?
Plans
Self-efficacy
Skills &
behaviour
Implementation
intentions
Mastery
experiences (SCT)
Vicarious
experience (SCT)
Persuasion (SCT)
Self-observation
(SRT)
Support
Mood
management
Stimulate action and coping planning —
and plans for self-reward — by texts,
multiple prompts and diary assignments.
Imagine and write down previous mastery
experiences. Point out to clients what is
mastered until now (e.g., you’ve been
smoke-free for X days!).
Provide stories of mastery/success from
other quitters, and encourage identification
of such stories in own environment
Communicate optimism about the
outcomes and point out that change is
not an instantaneous venture
Stimulate self-observation
Write a list of supporters, encourage
contact and provide suggestion for
contact letter.
Provide techniques to improve mood.
Provide stress and mood management
and motivational boosters.
AP must include specification of when, where and how to act. CP must
include identification of high-risk situations and coping responses.
Include plans of self-reward.
Beneficial with domain similarity between previous and current chal-
lenges. Could also be used for just-in-time therapy in critical situations.
Requires identification with model.
Enhanced by the prior development of a therapeutic alliance, confidence
in treatment provider.
Requires the identification and notification of potential supporters in
own network.
Some general tips may be provided as part of a psychoeducational
approach (i.e., in advance of the challenging situation). Include just-in-
time therapy for mood management.
part of the plan. By exploiting the unique possibilities
and strengths of each channel the design team hoped to
increase the persuasiveness. Adding proactive elements
to a digital intervention has been shown to significantly
improve both the return rate and efficacy (Clarke et al.,
2005). Additionally, there is a planned redundancy of
information between the various media channels (web,
IVR, and SMS) and the most important messages are to
be repeated across time, and across media channels.
As evident from Task 2.3, the psychological processes
that quitters experience are different across various time
points and these processes follow a particular chronology.
The chronology consists of processes that are common for
all quitters, as well as an idiosyncratic residual. The consid-
erations around timing eventually led the design team to
combine two different approaches to program delivery:
tunnelling (Danaher et al., 2005; Fogg, 2003) (addressing
common factors) and just-in-time therapy (Shiffman,
2006) (addressing idiosyncratic needs).
Tunnelling: the core organising principle. Program
content should be organised according to the psychologi-
cal processes that people experience at certain time points
(Kraft et al., 2009). Obviously, this cannot be accom-
plished with a static and hierarchically organised web
page, since such a site would require a tremendous
amount of navigation and cognitive processing from the
client, hence risking cognitive overload and program
dropout. One way to solve this in practice is to organise
the program content into multiple components sequen-
tially made available to the client for a restricted time
period: tunnelling (Danaher et al., 2005; Fogg, 2003).
Tunnelling is the core organising principle of the current
program, that is, the client progresses through a predeter-
mined sequence of modules. Here freedom to navigate is
immensely restricted, as compared to providing all of the
information simultaneously on a menu-based web page.
Another justification of tunnelling is that the sheer abun-
dance of contact points will probably contribute to both
increased awareness of the client’s own quit attempt and
to continued self-observation.
Media channels and their usage: bibliotherapy and
just-in-time therapy. A majority of the methods and
strategies selected in the previous step are compatible with
bibliotherapy and a psychoeducational approach, which is
feasible to deliver by the internet. Hence, an approach
based on bibliotherapy served as the backbone of the
program, and most materials were to be delivered in the
form of written web pages. Mobile phone text messaging
(SMS) was adopted as an important proactive channel,
used as a supplement for part of the bibliotherapy
approach (and for prompting purposes). Finally,
Interactive Voice Response (IVR) technology was to be
used as an additional part of the bibliotherapy approach,
by delivering prerecorded messages by phone. In addition,
two forms of just-in-time therapy (Shiffman, 2006) were
included: a craving helpline and a lapse detection and
relapse prevention system. Since most people carry their
mobile phones most of the time, IVR and SMS compo-
nents are particularly suited for proactive elements and
for providing reactive services that are available 24/7.
The Internet was to be used in three ways: (1) proac-
tive e-mails to prompt log on; (2) the reactive web
content; and finally (3) an interactive diary, ideal for
cognitive and behavioural assignments, was included as
an integral part of the web content. The main purpose of
the e-mail is to deliver the specific link to the web page
of that particular day, and to ensure a simple log in pro-
cedure (i.e., logging in by clicking the link). The link is
unique to the user and the particular day, hence, reliable
data on individual program adherence is available.
Task 4.2: Developing Program Materials
To allude to a personal relationship, all e-mails started
with the client’s first name (i.e., personalisation), and the
IVR calls typically started with a greeting followed by an
introduction as if Happy Ending was a person (i.e., a
helper, a friend or a therapist). Similarly, all of the text
messages (SMS) and the e-mails were ended with a
greeting/salutation and then signed ‘Happy’ (e.g.,
‘regards, Happy’; ‘cheers, Happy’; ‘talk to you later,
Happy’; ‘congratulations from Happy’ etc.). Moreover,
the language was kept as simple as possible, and was rel-
atively informal in tone. Oftentimes, personal pronouns
were used and the active voice was preferred to the
passive voice, this was true for all channels.
All this was done to foster confidence, personal com-
mitment and alliance. Even simple personalisation
strategies are believed to have positive effects on credi-
bility (Fogg, 2003), treatment adherence and treatment
efficacy, though the actual causal mechanisms are
unclear (Webb et al., 2005).
Start of program: providing a psychological contract.
When registration is finalised, the clients are asked (by e-
mail) to complete a web questionnaire containing a
psychological contract. In the questionnaire the participant
explicitly confirms/accepts: that he/she is joining the
program voluntarily and because he/she is motivated to
quit smoking; that active participation and active involve-
ment are crucial success factors; and a willingness to follow
the program as instructed. This is done to engender an
autonomous regulation of the behavioural goal, which will
— according to self-determination theory — result in reg-
ulation through identification or integrated regulation and
hence greater involvement in own quit attempt and in the
intervention program (Ryan & Deci, 2000).
Overall structure of the program: the three phases. The
program consists of three phases, a precessation prepa-
ration phase, a 1-month active quit phase, and an
11-month follow-up phase. In the two first phases the
client communicates with the program through the inter-
net and by means of mobile phone with multiple daily
contact points between client and program. In the follow-
39
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Developing an ICT-Based Cessation Intervention
up phase, however, the number of contact points is
reduced to a few per week, and all communication
between client and program is by means of mobile phone
(i.e., SMS & IVR). See Table 4 for details with regard to
number of contact points per medium for each phase.
The e-mails and the web content. The internet is applied
during the preparation phase and the active quit phase.
Each day, the client receives an e-mail with a link to
today’s web page (as described in Task 4.1). The program
includes a total of 44 unique web pages. All clients are
given access to the same material in the same sequence,
that is, the content of the web pages is not tailored to
each client. The web page of the day consists of a ‘front
page’, with a short menu on the left side, from which
additional material and the diary are available. Appendix
A shows the graphical appearance of such a page. For
each day, the most important material is presented on
the front page, while secondary/additional material is
available from the left menu. The client is instructed to
read the front page and do the diary assignment every
day, and to read the additional material when they feel
that the topic is relevant or interesting to them.
Appendix B contains the complete textual content
(English translations) from three sample days.
Two topics are repeated for each day in the active
quit phase. First, each day a new issue to stimulate nega-
tive attitudes towards starting to smoke again is
presented (i.e., negative information about the tobacco
industry). Second, each day a new issue designed to
heighten the client’s awareness of the positive short-term
consequences of abstinence is presented. Typically, the
issue is related to the healing processes taking place
during the early phases postcessation (e.g., today your
blood pressure is reduced to that of a nonsmoker). The
positive health message is first briefly presented in the
reactive morning call described below, and then elabo-
rated on the web.
The quit diary. The quit diary contains cognitive or
behavioural tasks. Usually, the actual task is preceded
with a short story, considerations of brief comments to
stimulate thinking and sometimes examples of responses
from other (imaginary) clients are provided. On nearly
every day, the diary contains text boxes in which client
may write down answers and notes to the queries.
Oftentimes, the task is introduced one day ahead (akin
to a home assignment) to stimulate reflection. In a few
days, practical tasks are provided instead of writing (and
thinking) tasks. Following the principles of motivational
interviewing (DiClemente, 1991; Miller & Rollnick,
1991) the diary avoids arguing for cessation and allows
the smoker to be ambivalent about quitting (roll with
resistance); for example, by asking the client about the
positive sides of smoking. This is done to make the client
feel accepted in spite of his/her previous choices about
smoking, and to foster a therapeutic alliance and confi-
dence in the treatment provider.
Many of the tasks are not explicitly related to smoking
cessation; in these, the client may choose to write on more
general topics or to write specifically on smoking cessa-
tion. Unlike the other web content, the quit diary entries
from all of the preceding days are available to the client,
that is, the client can browse back and forth (by the touch
of buttons) to read the various tasks and the notes he/she
made on that particular day.
The SMS text messages. The SMS text messages come in
two categories: standard messages and auxiliary mes-
sages. All clients who complete the program receive 260
standard educational and motivational messages. The
messages overlap with the other program content. In
fact, most messages are used to underscore the most
40 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
Table 4
Overview of the Contact Points Between Client and Intervention Program in the 2-Week Preparation Phase, the 1-Month Active Quitting Phase,
and the 11-Month Follow-Up Phase
The three phases of the program
Channel The 2-week The 1-month The 11-month
preparation phase active quitting phase follow up phase
(14 days) (30 days) (334 days)
E-mail one e-mail every day one e-mail every day none
Web page and diary a new unique web page a new unique web page
and a diary assignment every day and a diary assignment every day none
SMS text messaging two each day three each day on average: one each week
The craving helpline (IVR) not available available 24/7 available 24/7
The reactive none one each day one each day for
morning call (IVR) the two first weeks only
The proactive none one each day one each day for
evening call (IVR) the first four weeks, then
Wednesdays and Sundays for
four weeks, and then Sundays
only for the last nine months
Note: Additionally, IVR and SMS reminders are sent to the client if he/she does not perform the morning call or the evening call. In the first weeks of the follow-up phase the number of SMS
text messages is gradually reduced from two each day to approximately one each week.
important educational issues on the web. Standard mes-
sages also include messages related to the program
structure, that is, information of what will happen and
on the other components of the program (e.g., from
now on, there are no more web pages; this was the last
day with a morning call; remember to call the craving
helpline when experiencing serious craving; remember
your practical assignment). Seven messages are related to
NRT (reminders of obtaining it, wearing it and to use it
regularly). In addition to the standard messages, auxil-
iary messages are sent to a client when the client does
not perform the morning call or when he/she does not
respond to the evening call.
The reactive morning call: pointing to the short-term
positive consequences of quitting. From the second day
in the active quit phase, and 6 weeks onwards, the client
is instructed to call the program every morning. Upon
calling, the client will hear a brief prerecorded message
about one of the short-term positive consequences of
quitting (see Appendix B). This message is usually
further elaborated on the web page that day.
The proactive evening call: a combined lapse detection
and relapse prevention system. Happy Ending includes
an IVR-based lapse detection system. It entails the par-
ticipant being called by ‘Happy’ every evening/night, and
asked whether he/she has been smoking that day.
Smokers will be offered relapse prevention therapy. This
procedure, including the relapse prevention therapy, is
described in detail in Appendix C. The therapy consists
of a prerecorded dialogue between a smoking cessation
counsellor and a client having had a slip. The therapy
described in Appendix C is one out of five therapies,
which all have a similar scope and overlap in purpose.
Apart from the five different therapies the procedure of
the proactive evening call is the same each evening. The
system will remember how many slips each client has
reported and select the therapy accordingly. The purpose
of the therapy is to induce the participant to attribute
the slip to situational factors (thereby preventing nega-
tive emotions and a full-blown relapse) (Marlatt, 1985);
to realise what is achieved by being abstinent up until
now (mastery experience) (Bandura, 1997); finally and
most importantly, make the quitter accept that if he/she
relapses to smoking, it is part of a deliberate decision
and not something that the person is more or less pow-
erless to prevent.
The craving helpline. Happy Ending contains an IVR-
based craving helpline. As part of the SMS and web
content, participants are repeatedly encouraged to make
a plan of calling the helpline every time they are
tempted to have a cigarette — that is, making use of the
principles of implementation intention and coping
planning (Gollwitzer, 1999; Orbell & Sheran 2002;
Sniehotta et al., 2005). Upon calling, clients will hear a
prerecorded IVR-message:
Thank you for calling. You have done the right thing by
calling the Happy Ending Helpline. In a moment we will
give you effective help for the kind of problem you are expe-
riencing right now. In the meantime move away from where
you are, for instance into another room, while you listen to
these three choices. Enter 1 if you feel down or depressed
and in need for a little encouragement. Enter 2 if you are
under stress and feel like you need a smoke to cope with it.
Enter 3 if you feel that your motivation is running out and
you need a little kick in the back to stay smoke free.
With the push of a button, clients can hear a therapeutic
message specifically designed to (1) regulate negative
affect, (2) regulate stress or (3) boost motivation. The
system keeps track of which of the 48 messages the client
has already heard and which they are yet to hear. Each
message lasts for 3–5 minutes. An eventual positive
result from the provision of therapuetic messages may
be explained by (1) creating an implementation inten-
tion, (2) improved mood regulation (Kenford et al.,
2002), (3) distraction or (4) a combination of the above.
The follow-up phase. Happy Ending offers an 11-month
follow-up phase. During this phase, the logging off pro-
cedure continues daily for another four weeks, on
Wednesdays and Sundays for another two weeks, and
then on Sundays only for the remaining follow-up
period. Furthermore, the participants have access to the
craving helpline during the whole follow-up phase, and
the quitter receives a number of encouraging SMS and
IVR messages during this phase (see Table 4).
Task 4.3: Pretest the Program Materials with the Target Group
and Implementers
The program material was tested with the target group,
and feedback was collected from two focus groups
having weekly meetings and by in-depth interviews with
a few selected individuals. Based on this feedback, the
texts were adjusted and simplified. However, no major
revisions with regard to program objectives or program
structure were deemed necessary.
IM Step 5: Adoption and Implementation
The program was planned to be implemented on a com-
mercial basis, hence the implementers overlapped with the
program developers. The intervention program is primar-
ily meant to be used by individual quitters. The quitters can
be recruited from a dedicated website. Smokers enrol in the
program by paying the fee electronically on this website.
After payment, they register electronically by reporting
their name, e-mail address and
mobile
phone number.
Additionally, the intervention has been marketed to private
companies, and been made available to the smoking
employees. When the company has paid, however, each
participant follows the program on an individual basis and
the company has no access to individual data on program
adherence or behaviour outcome.
Happy Ending has been advertised in various media,
including television commercials, Googleads, a dedi-
cated web site, newspapers, and online newspapers.
41
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
Currently, the original version of the intervention (i.e.,
Happy Ending) is taken out of service, and the future of
the program on the Norwegian market is uncertain. The
intervention was available on the market from October
2003 until December 2008, serving nearly 4,000 clients.
Pharmaceutical companies, however, currently license
the Happy Ending template, and have developed inter-
ventions that are based on Happy Ending. These
interventions are offered as an adjunct, to purchasers of
smoking cessation products.
IM Step 6: Evaluation
The feasibility of the intervention program was demon-
strated during piloting and the early commercial phase of
the intervention, and confirmed in two RCTs. After feasi-
bility being established, it was decided that the most
important step in the evaluation was to perform an effect
study employing the most rigorous methodology, that is, a
randomised controlled trial (RCT) applying intention-to-
treat principles. At the time, comparable trials had only
documented a treatment effect for up to 3 months
(Rodgers et al., 2005; Strecher et al., 2005; Swartz et al.,
2006) Hence, assessment of the long-term effect at 6
and/or 12 months postcessation was deemed important.
From the outset, the intention was to test the inter-
vention both as a standalone intervention and with the
simultaneous use of NRT. Due to a flaw in the recruit-
ment procedure (NRT being part of the inducement for
participation), however, it was necessary to perform two
RCTs. First, an RCT in which NRT was provided for sub-
jects in both arms of the experiment, that is, the
treatment and the control group (Brendryen & Kraft,
2008; Brendryen et al., 2008; Brendryen, 2009). Second,
an RCT in which neither subjects in the treatment group
nor subjects in the control group received NRT
(Brendryen & Kraft, 2008; Brendryen et al., 2008;
Brendryen, in press).
In the intervention, the clients were thought to dis-
tinguish between lapse and relapse, and told that the
occurrence of a lapse would only lead to relapse if the
client interpreted the lapse as a relapse and deliberately
chose to start smoking again. Due to this particular
focus on relapse prevention in the program, a main
outcome that would have allowed for a few slip-ups was
required (i.e., repeated point abstinence at 1, 3, 6 and 12
months postquit; point abstinence was defined as ‘not
even a puff of smoke for the last seven days’). A printed
self-help booklet (Norwegian Directorate of Health,
2007b) was chosen as control treatment, because simple
self-help material as a stand-alone intervention has, at
best, very little effect (Lancaster & Stead, 2005a).
Moreover, compared to a waiting list control or a primi-
tive purpose-built static web page, a booklet will stand as
a credible and realistic treatment for most clients, pro-
vided that it is developed by a credible institution (i.e.,
The Directorate of Health) and distributed by a credible
source (i.e., researchers at the University of Oslo). This
means that it was not the channels that were tested, but
the intervention as an integrated whole.
The main finding from trial one (with NRT)
(Brendryen & Kraft, 2008) was that repeated point absti-
nence was significantly higher in the treatment group
(22.3%) compared with the control condition (13.1%;
OR = 1.91, 95% CI: 1.12–3.26, n= 396, p= .02).
Improved adherence to NRT and a higher level of
postcessation self-efficacy were observed in the treat-
ment group compared with the control group. The
increased adherence to NRT, however, did not mediate
the treatment effect. The main finding, from trial two
(without NRT) (Brendryen et al., 2008), was that
repeated point abstinence was significantly higher in the
treatment group (20.1%) compared with the control
condition (6.8%; OR = 3.43, 95% CI: 1.60–7.34, n= 290,
p= .002). The improved levels of self-efficacy observed
in the treatment group (at the end of the initial prepara-
tion phase) compared to the control group, did partially
mediate the treatment effect. No interaction effect
between experimental condition and subject characteris-
tics (including age, gender or level of education) was
found in any of the trials (Brendryen & Kraft, 2008;
Brendryen et al., 2008; Brendryen, in press). Hence,
developing separate interventions for these identified
subgroups was not deemed necessary.
Trial 1 (Brendryen & Kraft, 2008) was the first RCT
documenting the long-term treatment effects of such an
intervention, hence adding to the promise of digital
media in supporting behaviour change. The main con-
tribution from Trial 2 was to extend generality of the
finding beyond those interested in using NRT, and con-
firming that psychological mechanisms were more
important to the intervention than the pharmacological
mechanism (NRT use). The effect sizes (i.e., OR) for
long-term abstinence found in these two trials
(Brendryen & Kraft, 2008; Brendryen et al., 2008) are in
the range of those reported in meta-analyses of tele-
phone counselling (Stead et al., 2006), group counselling
(Stead & Lancaster, 2005), and individual face-to-face
counselling with smoking cessation specialists
(Lancaster & Stead, 2005b).
Between the commencement of the intervention in
2003 and its closure in 2008, approximately 3600
persons used the intervention, which is equivalent to 1%
of the target group.
Discussion
The aim of this article was to provide a comprehensive
description of the development of the smoking cessation
intervention Happy Ending, using the IM protocol
(Bartholomew et al., 2006). This description links the
phases of the intervention development to theory and
empirical evidence and meets the recent calls for more
thorough descriptions of interventions (Dombrowski et
42 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
al., 2007; Gutmann et al., 2004; Michie & Abraham 2008;
Schaalma & Kok, 2009; Strecher 2008; Walters, 2006).
The article outlined the planned development of an
innovative, fully automated intervention program that is
delivered by means of the Internet and mobile phones.
The program consists of over 400 contacts across four
media channels (SMS, IVR, e-mail and web) covering a
2-week preparation to quit phase, a 1-month high inten-
sity active quit phase, and an 11-month low intensity
follow-up period. The intervention further includes an
interactive quit diary providing the quitters with cogni-
tive and behavioural assignments. The design of the
intervention is novel in that it combines four different
media channels. Moreover, the combination of extensive
tunnelling (Danaher et al., 2005), based on the natural
chronology of quitting, and the two forms of just-in-
time (Shiffman, 2006) therapy are also novel. The first
form of just-in-time therapy is a craving helpline,
mainly targeting negative affect (Kenford et al., 2002;
Shiffman & Waters, 2004) and the provision of relapse
therapy (relapse prevention) based on a daily assessment
of the target behaviour (lapse detection).
The article illustrates that IM can be a useful tool for a
posthoc description of interventions. Our article illus-
trates how a needs assessment documenting the necessity
for new types of smoking cessation interventions fed
program objectives. Subsequently, it illustrates how
theory, in particular self-regulation theory (Baumeister &
Vohs, 2004) and theories on relapse prevention (Brandon
et al., 1990; Marlatt, 1985; Ockene et al., 2000; Shiffman et
al.,1996), can guide the specification of general program
objectives into specific behavioural outcomes and perfor-
mance objectives. It further describes the specification of
program change objectives targeting the determinants of
the performance objectives, and how the change objec-
tives guided the further development of the intervention
program, both in terms of the selection of theory-based
behaviour change methods and in terms of the principles
underlying the design of intervention strategies and mate-
rials. It describes why and how change methods derived
from social cognitive theory (Bandura, 1997), cognitive–
behaviour therapy (Curven et al., 2006), motivational
interviewing (Miller & Rollnick, 1991) and relapse pre-
vention (Marlatt, 1985) were included in the final
intervention, and how insights from therapy-supported
self-regulation (e.g., Kraft et al., 2009; Piasecki et al., 2002;
Rothman et al., 2004) guided the structure of the inter-
vention program. As such, it unravels the logic of the
development of the current intervention program by
linking objectives, theories and actual program materials
and activities.
Apart from illustrating the sound theory and evi-
dence base of Happy Ending, the IM-based analysis
illustrates some weaknesses in the program development
process, mainly referring to the anticipation of program
implementation and maintenance. Happy Ending was
disseminated on a commercial basis by a small private
company (i.e., direct sales to individuals and compa-
nies), which turned out to be challenging in terms of
high advertisement costs and low recruitment. A large
governmental organisation (or a nongovernmental
health maintenance organisation) may have provided a
better platform for dissemination, because such an
organisation has an existing organisational infrastruc-
ture suitable for an effective and large-scale distribution
of interventions and it may benefit from synergy effects
between the running of tobacco campaigns and the
advertisement and dissemination of the intervention. IM
recommend that cooperation between intervention
designers and potential implementers (program
adopters) of an intervention is established from the
outset (Bartholomew et al., 2006).
The efficacy of Happy Ending has been demon-
strated in two previous randomised controlled trials. In
these trials, Happy Ending was compared to a printed
self-help booklet and showed a clinically and statistically
improved abstinence rate at 12 months postcessation
(Brendryen & Kraft, 2008; Brendryen et al., 2008). The
last step of the IM approach is to make an evaluation
plan. Also on this step, the actual course of action devi-
ates notably from the IM approach in that the evaluation
of the intervention has focused almost solely on the effi-
cacy of the intervention, in terms of behaviour change,
at the expense of process evaluation. A thorough assess-
ment of all of the potential process variables may have
informed more specifically on the degree of success in
reaching each of the program objectives (i.e., those listed
in Table 2). Hence, we know that the intervention is effi-
cacious, but we do not know the relative contribution
from each causal pathway (as outlined in the set of
learning and change-objectives).
In sum, this article disentangles the rationale of an
ICT-based smoking cessation intervention previously
shown to be efficacious, and may inform systematic
reviews, theory development and intervention develop-
ment. Herein, the IM protocol was used as a tool for
intervention description as opposed to intervention devel-
opment. It demonstrates how IM can be useful for the
writing of posthoc intervention descriptions. IM helped
us disentangle the rationale of the intervention and to
present the rationale in a structured manner. In this way
we hope to have opened up the black box (Strecher, 2008)
named Happy Ending.
Acknowledgments
This research was made possible through the coopera-
tion and co-funding between the University of Oslo,
Happy Ending AS and the Norwegian Research Council.
Conflicts of Interest
Author Pål Kraft has a financial interest in the interven-
tion under scrutiny, as a shareholder of Happy Ending
43
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
AS. Authors Håvar Brendryen and Herman Schaalma
declare to have no financial interest in the intervention.
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46 JOURNAL OF SMOKING CESSATION
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APPENDIX A
Screenshot of a Sample Web Page
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48 JOURNAL OF SMOKING CESSATION
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Hello [client’s forename]!
Here is the link for today’s web page: [a hyperlink leading to the web page below —
unique to day and person]
Regards
Happy
P.S. Remember the quit diary!
A slip-up does not mean failure!
Happy Ending Rule #4 is the most important rule: ‘You will give up again the next day
after a slip-up’. [rule 1 through 3 were presented the previous three days]
Imagine you have stopped smoking and have been smoke-free for four days.
Then something happens that makes you have a few cigarettes in the evening.
What do you think the next morning?
‘Damn it! I’ve blown it now. I’ve started smoking again. It didn’t work this time (either).
I’ll try and stop some other time’. And so you light up the first cigarette of the day.
This is the big misunderstanding when it comes to stopping smoking.
EVEN IF YOU HAVE A (FEW) CIGARETTE(S), IT’S NOT A DISASTER!
All that may have happened is that your self-respect has taken a little knock.
That is why you must continue to stop smoking the next day as if nothing had happened.
This was the last of the Happy Ending Rules. Read below to have all four rules repeated.
If you follow these rules we promise you that you will have a strong probability of giving
up smoking.
Happy Ending Rule #1. You will participate actively all the time.
Happy Ending Rule #2. You will call the Craving Helpline straight away.
Happy Ending Rule #3. You will use nicotine substitute.*
Happy Ending Rule #4. You will give up again the next day after a slip-up.
*Remember special rules apply if you are pregnant or have a heart condition!
Stop Smoking Diary Day 4: Taste and smell before
Yesterday you were smelling and tasting things. We asked you to breathe in the air in a florist’s
shop, taste some good food or a glass of red wine.
Write some keywords:
What were your thoughts when smelling or tasting things? [textbox for user input]
What were your feelings when smelling or tasting things? [textbox for user input]
Now on to today’s task, which is a ‘reading and feeling’ exercise.
The most important factors in stopping smoking are motivation and a sense of control. The
fact that you really want to stop and you really believe you can do it.
Perhaps you need to boost your self-confidence a little bit just before you stop? Here is an
exercise which many people find helpful.
APPENDIX B
The Complete Intervention Content From a Sample Day From Each of the Three Phases
A Sample Day From the Preparation Phase
E-MAIL 05:00 a.m.
WWW
(front-page)
available all day
WWW (diary)
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Read this list out loud. If it’s difficult to do that at the moment, you can read it in your head,
stopping and thinking about each statement. Let’s go!
I have faith in myself in relation to other people.
Many people are supporting me in giving up.
I feel free in relation to other people.
I decide what I want to do.
I have decided to stop.
I accept myself for what I am.
I realise that I can improve.
I am experiencing an inner freedom.
I look forward to being smoke-free.
I have faith in my own experience.
I have faith in my own resources.
I shall succeed in giving up.
I dare to do well when I want to.
I decide things for myself.
I like myself.
I want to have a good life.
I am stopping smoking!
Recognise how you are feeling now. You are ready to tackle anything!
[Submit button]
Sunday is getting closer — your last day as a smoker.
On Sunday evening you will have your last cigarette. Even though there are a few days to go,
you can start preparing yourself for a couple of things you must do on Sunday evening.
Remember to buy nicotine substitute so you have it ready for the weekend! Go to the
pharmacy — you will get good advice there! You can also buy some of the products where
you do your food shopping. Remember that you should have nicotine substitute at home on
Monday morning. Because you are giving up smoking then!
There are a couple of things you must do on Sunday, before you go to bed.
You should clear away all ash trays and everything else that could remind you of smoking. And
look through drawers and cupboards for cigarette packets or tobacco. Throw away any you find.
You should also stick up yellow labels. On these you should write: ‘I will succeed in stopping’.
Stick the labels on the fridge door, in the bathroom, beside the TV etc. The point is that you
should continually show yourself that you are going to make it (A bit ‘childish’? It works!)
When you wake up on Monday you will be a nonsmoker. There is nothing in the house to
remind you about smoking. You stick on a nicotine plaster or pop some gum in your mouth
and you see yellow stickers all around to give you strength. You are ready!
Think through potential slip-up situations beforehand.
The best way of avoiding slip-ups, and possibly finally failing altogether, is to prepare
yourself for the slip-up situations.
APPENDIX B (continued)
The Complete Intervention Content From a Sample Day From Each of the Three Phases
WWW
(additional
material 1)
WWW
(additional
material 2)
A slip-up is no great catastrophe. Look on any slip-ups as a little step backwards, before you
continue ahead at full speed. Most of us are creatures of habit. The same situations are
repeated quite regularly. What situations do you think might be difficult for you?
Yesterday was Wednesday. Try to think about when you smoked yesterday. Start with the
morning; perhaps you had your first cigarette after breakfast or on the way to work? And
afterwards, when did you smoke during the day?
What is it that distinguishes your smoking pattern? I often smoke:
after a meal — on the way to or from work
when I have a coffee break
when I am stressed when I need a livener at home or at work
when I am going to relax and enjoy myself
when I am with friends or family
when I am at a party or out with somebody.
If you are aware of these situations, you will be better able to decide that you are not going to
smoke when they occur. You can tell yourself in fact that when you encounter these situations
you will not be tempted to smoke. Again, it might sound a bit naive, but it works!
Walking — the best medicine!
Something as simple as taking a short walk can have fantastic effects.
And it doesn’t take very much.
After giving up smoking, the craving to smoke is often associated with the onset of negative
feelings. You’re a bit down, frustrated, angry or bored. To pay for the negative feelings you get
the desire for a cigarette. Here’s an alternative!
Research shows that if you take a 10-minute walk, your mood will improve enormously and
stay that way for up to two hours afterwards! And you don’t need to rush along with your
tongue hanging out. Go quickly at your own pace. You don’t need to raise a sweat.
One other thing: If you walk for a total of 30 minutes every day, you will burn up about
300 kcal. That’s about the same as the extra you normally take in between meals when you
give up smoking.
So you’ll be both happier and thinner from taking a walk! Plus, the craving to smoke will be
less! (Absolutely true!) You should therefore plan out a 10-minute walk at work, as well as
where you live. Walk where you want to. In a park, along a footpath, past some shop windows.
Decide for yourself! Go where you feel good. Try to take these walks a few times each day.
You’ll be happier for it! You’ll be more effective at work too!
Once you’ve stopped you can use some of the smoking breaks you used to have at work to go
for a brisk walk.
Perhaps you can get someone to walk with you? That would be even nicer — you’re going to
like this!
Did you like that about being able to have a slip up? But the BEST thing is NOT to have a
slip-up. Thought I’d just mention it … Regards, Happy.
How was that walk? Should do it before you go home, if you haven’t yet. Just thought I’d say
so . . . have a nice evening! Regards, Happy.
50 JOURNAL OF SMOKING CESSATION
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WWW
(additional
material 3)
SMS 10:50 a.m.
SMS 01:30 p.m.
APPENDIX B (continued)
The Complete Intervention Content From a Sample Day From Each of the Three Phases
SMS 07:30 a.m.
IVR morning
E-MAIL 05:00 a.m.
WWW
(front-page)
Available all day
WWW (diary)
WWW
(additional
material 1)
Remember to log on. 815 86 099. [i.e., the morning call] Check whether you need to stock up
on your NRT to see you through next week Regards, Happy
Hello, you are now logged on to Happy Ending. Your blood is now carrying 20% more
oxygen. You are in noticeably better form already. Find a staircase and test it out. Read more
on the website.
[Identical to the preparation phase.]
You have already reduced your likelihood of a heart attack!
This morning you heard on your mobile that your heart is now beating at least 20,000 fewer
times during a day. The body’s fantastic repair work has been in full swing for some time.
What’s more, your blood pressure, which was raised due to your smoking, is now reduced.
These two things alone mean that you have already reduced your likelihood of a heart attack.
But it’s not just your heart that’s feeling better. If you put together all the health notices you
have had over the last five days, you will see that you already have a much improved overall
state of health. Congratulations!!!
Your first weekend as a nonsmoker is almost here. And the first weekends are danger periods
for slipups and failure. That’s why it’s time to bring out the plan you made for this weekend.
WHY You have come a long way now. You won’t destroy it now by being careless this
weekend! You are over the worst craving and you will soon have managed a whole week as a
nonsmoker. In short, you are well on the way to stopping for the last time.
Keep your mobile with you all day. The Craving Line is only a keystroke away! You remember
the number: 370 35 909. And you remember that it only costs the same as a standard phone
call — don’t you?
Stop Smoking Diary day 5. Gratitude.
We sometimes need our spirits lifting a little. You feel that you’d like to be a bit more satisfied
or happy. One way of achieving this is to compile a ‘Gratitude list’. The idea is to write down
3–5 things for which you are grateful. These can range from the simple and banal (something
you’re looking forward to on TV) to the wonderful moments in life (seeing your child take its
first steps).
When you feel in need of a lift, it may be worth writing a list like that. You can gradually
refine it by regularly including new things. We’ll begin this now. Write down 3–5 things you
have reason to be thankful for.
[textbox for user input]
Now you can stand to hear the truth about ‘light’ and ‘mild’.
Light cigarettes are the biggest health bluff ever!
When someone smokes a light cigarette he will quite naturally draw the smoke down harder
into the lungs, to get enough nicotine. This is the clear result of research in many countries
around the world.
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APPENDIX B (continued)
The Complete Intervention Content From a Sample Day From Each of the Three Phases
A Sample Day From the Active Quit Phase
WWW
(additional
material 2)
WWW
(additional
material 3)
This way of smoking causes the smoke to penetrate further into the lungs and leave tar and all
the other dangerous substances there. So light cigarettes are not less damaging. If that’s what
you thought. But what about the tar content that is stated on the packet? The truth is that this
figure is measured by so-called ‘smoking machines’. Flesh and blood people smoke light
cigarettes in quite a different way and take in up to 8 times as much tar as is stated on the
packet. It isn’t for nothing that the World Health Organization has called them ‘the biggest
health bluff ever’.
Are you angry at the tobacco industry? Use your anger to build up the ‘threshold’ against
starting again.
It is possible you were fooled by the light cigarettes. But don’t think back over how ‘stupid
you have been to smoke’. Instead, think about how smart you have been to stop.
And who is the winner in the end? It’s you!
The plan for the weekend.
A week ago you planned your first weekend as a nonsmoker. If you need to make any
adjustments it’s a good idea to do it today.
Now there’s no doubt about it. You’re going to make it! The worst part is behind you. Very
many of those who don’t make it give in before day five. Your first weekend as a nonsmoker
is approaching. No reason to give in now! Follow the plan you have made. You made it so that
it would be easier for you to stay smoke-free through the weekend.
If you haven’t made a plan for the weekend yet, it’s important that you do it today. And
promise one thing? If you should slip up and smoke this weekend, you’ll give up again the
next day — remember? You will find more information on the website about what to do if
you should slip up after logging off this evening, tomorrow or on Sunday. Have a nice
weekend!
A friendly greeting from your heart.
In the very first days it was the lungs that began to repair themselves. Now it is the turn
of the blood circulation and the heart. You are making rapid progress towards a huge
improvement in your health!
A smoker’s heart beats 10–25 times more per minute, because part of the blood’s capacity
to carry oxygen is out of action. This can add up to as much as 36,000 extra heartbeats a day.
Because you smoked, you were from 2 to 6 times more likely to have a heart attack. Even just
smoking ‘the odd cigarette’ increases the risk. There is no safe lower limit. But that’s quite
enough misery for now!
The important thing now is that you don’t smoke any more. So you don’t need to think about
it anymore. You have put that stage behind you. Over and done with!
Don’t say to yourself: ‘How stupid I’ve been. You haven’t been stupid at all. You just haven’t
been properly motivated before. Besides, smoking has had its positive sides. We have talked
about these before.
52 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
APPENDIX B (continued)
The Complete Intervention Content From a Sample Day From Each of the Three Phases
Think instead about how smart you are now, having put it all behind you. And let the daily
good news about your health built up a higher and higher threshold against starting again.
Conclusion: No reason to give in, now you’ve come this far.
Hello! It’ll soon be the weekend. Didn’t you get round to making a plan for the weekend
during the week or have you had some new ideas? Update your plan now. Regards, Happy.
Congratulations! Smoke-free for a whole working week. What did we say? You’re doing great!
Remember 370 35 909, the Craving Line, this weekend. Enjoy yourself. Regards, Happy.
[If not smoking] Bravo! It’s now a full working week since you stopped. If you keep this up
over the weekend, there is every indication that you have stopped for the last time. Have a
great weekend!
Remember to log on. 815 86 099. Regards, Happy
Hello, you are logged on. Smile! From now on, your risk of serious gum disease is reduced
by 80%. Yes, you heard correctly. 80%. Have a smiling day!
Do you want a bit of encouragement? Remember the tip about giving someone a
compliment? It rebounds on you. Just try it. Regards, Happy.
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Developing an ICT-Based Cessation Intervention
APPENDIX B (continued)
The Complete Intervention Content From a Sample Day From Each of the Three Phases
SMS 10:50 a.m.
SMS 03:50 p.m.
IVR 20:00 p.m.
SMS 07:30 a.m.
IVR morning
SMS 01:00 p.m.
A Sample Day From the Follow-Up Phase
54 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
APPENDIX C
A Transcription of the Combined Lapse Detection and Relapse Prevention System
The client is called by an automated IVR service in the evening. If the client does not respond to the first evening call,
the system will call up once more after 10–15 minutes. If the client still does not respond, he/she will receive a text
message (SMS), asking him/her to call ‘Happy’ whenever he/she have time. However, if/when the client picks up the
phone; he/she will hear the following pre-recorded message:
Hello and good evening! This is Happy Ending. I hope I’m not disturbing you too much. Press one if you have stayed smoke-free
today. Press two if you have smoked.
If the quitter presses one, he/she will hear an encouraging message (there is a new message each night), for example:
I thought as much! You’re still smoke-free. It’s really nice to know that it’s going so well for you. Keep hanging in there! You are ever
so close to giving up for good.
After the message above, the procedure is ended.
However, if the client presses two, he/she will hear:
You’ve pressed two. This means that you have had a slip-up. If you made a mistake and meant to press one, press star, then one now.
[Small pause — if star plus one is pressed, the current message is halted, and the encouraging message above is played]. Even
though you’ve had a slip-up, you still have an equally good chance of quitting. If you have already decided to continue the quit
attempt from tomorrow, press one now. If haven’t fully made your mind up, just wait a moment. [Small pause]
Then, if one is pressed, the client will hear:
Congratulations! You’ve made a wise decision. You will continue with Happy Ending as normal from tomorrow. With the experi-
ence you now have, you are actually even better equipped to stop than before. Have a nice evening!
After the message above, the procedure is ended.
However, if one is not pressed, the client will hear:
You will now hear something interesting which I think may help you to make your mind up. It’s a conversation between someone
trying to stop smoking and a therapist. Afterwards we’ll ask you a question.
This message is followed by one out of five pre-recorded dialogues between a smoking cessation counsellor and a
client having had a slip.
Counsellor: Hello again, … please sit down.
Client: Thank you …
Counsellor: Well, … how are things then?
Client: (dejected) (hmmm) not good… . I’ve started smoking again.
Counsellor: (surprised): OK… . What do you mean exactly?
Client: I had three cigarettes yesterday.
Counsellor: Right. So you had three cigarettes yesterday. How do you feel now then?
Client: (Huh) I feel … I don’t feel anything in particular. I feel disappointed.
Counsellor: What do you mean by that?
Client: Well … erm … I’m disappointed in myself of course.
Counsellor: Hmm … you feel disappointed in yourself. Why do you?
Client: erm … Because it just proves that I haven’t got the willpower and I’ll … I’ll probably never manage to give up.
Counsellor: OK… . Right then. So you’ve had three cigarettes. What happened?
Client: Well … I was out with some friends. We had a meal, drank some wine and it was a really pleasant evening. Most of the
others there were smoking too.
Counsellor: I see … So that’s when you had a cigarette. But what was it like earlier in the day, then? Hadn’t you been thinking about
smoking at all?
Client: Oh yes … I’d been really wanting a cigarette all day.
Counsellor: Yes, but what stopped you from actually having a cigarette then?
Client: Well, I’d decided to stop smoking, hadn’t I? So I managed to resist.
Counsellor: Have there been difficult periods before?
Client: Definitely. I’ve been tempted several times a day.
Counsellor: So, it’s been tough, then, several times a day. But you still managed to stick to your decision to stop smoking?
Client: Yes, I did …
Counsellor: So you’ve actually proved to yourself that you have strong willpower. Wouldn’t you say? … In fact, you’ve even proved it
several times a day.
Client: I suppose I have, … but not yesterday, obviously.
Counsellor: No you had a couple of cigarettes yesterday evening. But from what you’ve said, you were in a situation in which most
people would have found it difficult not to have a slip up. Isn’t that right?
Client: Yes, of course. Yes, that’s true enough.
Counsellor: So then, you are being really harsh on yourself when you say that you don’t have willpower.
Client: Yes … I suppose I am.
Counsellor: Do you know what this tells me? It tells me that you have strong willpower and can resist the urge to smoke. It was the
situation which arose yesterday evening that did it. It was simply too demanding for you and you had a slip-up, there and then. But
that situation is in now the past. Why should it mean that you have started smoking again?
Client: I don’t know … it was a slip. That’s what it was.
Counsellor: Just what it was. It was a culmination of everything in the situation that caused it. It was most definitely not a sign that
your will power is poor. After all, it’s been strong enough for several days.
Client: Well, yes, if you look at it like that …
Counsellor: It’s the same with everyone who slips up. That’s why the word slip is used. It’s an external situation which triggers it, but
the situation passes. So why shouldn’t you just continue to stop smoking, now that the situation is long since gone?
Client: Ha … I suppose there’s no reason why not, really.
Counsellor: So what does that mean?
Client: Oh no … (laughs) I suppose it means that you win?
Client: (Chuckles) You’re the winner, aren’t you! The way I see it, you are now stronger than ever. You’ve shown that you can stop again
after a slip-up, and you have learned from a risk situation, which you should maybe avoid for a while. So who’s the winner here
Client: I’ll be the final winner if I’m successful.
Counsellor: So, what do you think … do you have more or less chance of succeeding now?
Client: Well, when you look at it like that, I’d say there are more chances.
When the 3-minute long conversation is over, the client is asked the following question:
We’d now like to know whether you want to continue to stop smoking or whether you feel you have really failed. If you have
decided to continue with Happy Ending and stop smoking again from tomorrow, press one. If you think you have maybe failed
completely, press two.
If one is pressed, the message above starting with ‘Congratulations!’ is played to the client. If two is pressed however,
the client will hear message to induce an anticipated regret reaction:
You have pressed 2 and think that you have maybe failed completely. If you made a mistake and meant to press 1, press star then 1
now. [Small pause] Whatever you think right now, the fact is that you still haven’t completely failed. You’ve just had a quite harmless
slip-up. If you fail and start smoking again now, it’s because you have decided to. We will call you again in an hour’s time. During
this time you must decide whether you want to start smoking again. To help you, try pondering on this. How will you feel in a
month’s time if you decide to start smoking again now? And how will you feel if you continue to stop smoking. If you decide to start
again, of course we’ll accept this. We’ll speak in an hour, take care in the meantime.
[New call after an hour.]
Hello, this is Happy Ending again. We are now ready to receive your decision. Press one if you want to continue to stop smoking
tomorrow. Press two if you have decided to start smoking again.
When one is pressed, the client will hear the message above starting with ‘Congratulations!’ When 2 is pressed
however, this message will be played:
You have pressed 2. This means that you have decided to become a smoker again. If you made a mistake and meant to press 1, press
star then 1 now. [Small pause] So, you have decided to start smoking again. We must of course respect your decision, particularly as
you have considered this very carefully before making your decision. The best thing you can do now is to decide on a new date for
stopping — we are convinced that you will stop smoking one day. When that day comes, we hope that you choose Happy Ending to
be your friend and helper once again. We wish you luck meanwhile.
55
JOURNAL OF SMOKING CESSATION
Developing an ICT-Based Cessation Intervention
APPENDIX C (continued)
A Transcription of the Combined Lapse Detection and Relapse Prevention System
APPENDIX C (continued)
A Transcription of the Combined Lapse Detection and Relapse Prevention System
The decision is only respected until the next morning. Then the telephone rings, and the following message is played:
Hello and good morning! This is Professor Pål Kraft speaking. I am the medical representative in Happy Ending. Last night you
made the decision to start smoking again, and we respect this decision, of course. But I know from experience that next day people
can regret their decision a little. If you view the situation a little differently today, and want to continue to stop smoking, you still
have another chance. If this is the case, and you still want to continue with Happy Ending, press 1 when I ask you to make your
choice. Press 2 if you want to stick with your decision to start smoking again. Please press 1 or 2 now.
Again, the message above starting with ‘Congratulations!’ is played to the client if one is pressed. If two is pressed:
You have made a decision which is respected. You have weighed up the pros and cons and concluded that the time wasn’t right for
you to stop smoking. If you made a mistake and meant to press 1, press star then 1 now. [Small pause] We at Happy Ending thank
you for participating to this stage and hope that you can stop with us on another occasion. Good luck.
56 JOURNAL OF SMOKING CESSATION
Håvar Brendryen, Pål Kraft, and Herman Schaalma
... Including clinical support may result in improved outcomes [20]. However, limited description of what this clinical support involves has made it difficult to replicate, improve, and implement this type of human support for MHTs [20,[25][26][27]. ...
... Users with bipolar disorder may also specifically benefit from guidance in navigating self-management challenges [55]. To develop self-management support for LiveWell, we integrated information from empirically supported psychotherapies for bipolar disorder, the health psychology behavior change literature, and chronic disease self-management models [25,26,[30][31][32]37,38,40,41,[46][47][48][56][57][58][59][60][61][62][63][64]. ...
... To facilitate changes in these behavioral targets, the technology and coach deliver behavior change techniques (BCTs) that constitute the smallest intervention components impacting behavioral regulation [25,26,[30][31][32][58][59][60][61][62]. BCTs can be grouped into nonoverlapping clusters hypothesized to alter specific behavioral determinants involved in enacting target behaviors [61,62,[66][67][68][69]. Determinants and their corresponding techniques can be grouped into 4 domains: motivational determinants involved in developing an intention to engage in a behavior, volitional determinants involved in enacting the behavior, and environmental determinants and capabilities that impact both motivational and volitional processes. ...
Article
Full-text available
Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to recurrence of episodes, long episode durations, and persistence of interepisode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates, with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, timing of delivery, and the training and supervision for coaching support of the LiveWell technology. This support includes clearly defined and structured roles that aim to encourage the use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention.
... NCT02405117, NCT03088462). Description of intervention development is essential to support ongoing improvement and dissemination of technology-based mental health interventions [38][39][40][41][42], and thus, this paper describes the user-centered development of LiveWell. The development approach aims to ground LiveWell in the lived experiences of individuals with bipolar disorder to create an intervention that encourages the development and long-term use of self-management strategies for living well with bipolar disorder [43][44][45]. ...
... Content and tools for the app and coaching support were developed based on information from empirically supported psychotherapies for bipolar disorder [3,12,13,15], health psychology behavior change theories [39,40,[67][68][69][70][71][72][73][74], and chronic disease self-management models [75][76][77][78][79][80][81][82][83]. Design sessions and usability testing were then conducted to obtain user feedback on the overall app design, Daily Check-in, Daily Review, Foundations lessons, and the F2F coaching app training session. ...
... To support the ongoing improvement and dissemination of technology-based mental health interventions [38][39][40][41][42], we have provided a detailed description of the user-centered development process for LiveWell. This process suggests that individuals with bipolar disorder value target monitoring, personalization of goals and plans, and human support aids as self-management tools. ...
... NCT02405117, NCT03088462). Description of intervention development is essential to support ongoing improvement and dissemination of technology-based mental health interventions [38][39][40][41][42], and thus, this paper describes the user-centered development of LiveWell. The development approach aims to ground LiveWell in the lived experiences of individuals with bipolar disorder to create an intervention that encourages the development and long-term use of self-management strategies for living well with bipolar disorder [43][44][45]. ...
... Content and tools for the app and coaching support were developed based on information from empirically supported psychotherapies for bipolar disorder [3,12,13,15], health psychology behavior change theories [39,40,[67][68][69][70][71][72][73][74], and chronic disease self-management models [75][76][77][78][79][80][81][82][83]. Design sessions and usability testing were then conducted to obtain user feedback on the overall app design, Daily Check-in, Daily Review, Foundations lessons, and the F2F coaching app training session. ...
... To support the ongoing improvement and dissemination of technology-based mental health interventions [38][39][40][41][42], we have provided a detailed description of the user-centered development process for LiveWell. This process suggests that individuals with bipolar disorder value target monitoring, personalization of goals and plans, and human support aids as self-management tools. ...
Preprint
BACKGROUND Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. A combination of medications and psychotherapy improves outcomes, but accessibility of treatment is limited. Smartphones and other technologies have the potential to increase access to evidence-based strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. OBJECTIVE This study obtained user input to guide the development of LiveWell: a smartphone based self-management intervention for bipolar disorder. METHODS Individuals with bipolar disorder participated in an initial field trial focused on developing a self-report data collection platform followed by design sessions, usability testing, and a second field trial with the goal of developing a bipolar disorder smartphone self-management intervention. Participant feedback was obtained formally via structured interviews and questionnaires as well as informally during the second field trial coaching sessions. Iterative revisions to the application design were made based on participant feedback throughout all phases of development. A qualitative analysis of participants’ personalized anchors for mood, thought, and wellness ratings was utilized to better understand the signs and symptoms that participants identified as important for wellness self-monitoring. Thematic analysis of the second field trial’s exit interviews was used to better understand participants’ experience of the intervention and its delivery. RESULTS Our research team sought participant input to aid in the design and development of a smartphone-based self-management intervention for bipolar disorder. This process led to design revisions and provided insights into what participants valued. In discussing behavior change processes, participants emphasized the importance of managing early warning signs and symptoms and the central role of monitoring and social support in this management. Participants reported that personalizing their wellness rating scale descriptions and their plans for staying well was useful. Interestingly, when participants anchored a wellness rating scale rather than separate mood and thought scales, most anchors were categorized as behaviors. This suggests that a less directed approach may better capture participants’ experiences and needs. While participants found the current level of application personalization beneficial, they also requested more psychoeducational information and personalization. These requests lead to design tensions between individual participant preferences and the delivery of a generally useful evidence-based, self-management intervention for bipolar disorder. CONCLUSIONS This study emphasizes the importance of monitoring, evaluation and adjustment as well as the development of insight as key volitional and motivational factors that encourage behavior change. Participants also indicated that social support from the coach as well as involvement and engagement of family, friends and providers was important in terms of seeking and receiving assistance with behavior maintenance. Finally, personalization of digital mental health self-report tools such as scales, questionnaires and plans may enhance self-reflection practices as well as connection with core intervention content.
... Users with bipolar disorder may also specifically benefit from guidance in navigating self-management challenges [50]. To develop self-management support for LiveWell, we integrated information from empirically supported psychotherapies for bipolar disorder, the health psychology behavior change literature, and CDSM models [25,26,32,33,35,36,[41][42][43][51][52][53][54][55][56][57][58][59][60][61][62]. ...
... To facilitate changes in these behavioral targets, the technology and coach deliver behavior change techniques (BCTs) that constitute the smallest intervention components impacting behavioral regulation [25,26,[53][54][55][56][57][58][59][60]. BCTs can be grouped into non-overlapping clusters hypothesized to alter specific behavioral determinants involved in enacting target behaviors [59,60,[64][65][66][67]. Determinants and their corresponding techniques can be grouped into four domains: motivational determinants involved in developing an intention to engage in a behavior, volitional determinants involved in enacting the behavior, and environmental determinants and capabilities that impact both motivational and volitional processes. ...
Preprint
UNSTRUCTURED Despite effective pharmacological treatment, bipolar disorder is a leading cause of disability due to the common recurrence of episodes, long episode durations, and persistence of inter-episode symptoms. While adding psychotherapy to pharmacotherapy improves outcomes, the availability of adjunctive psychotherapy is limited. To extend the accessibility and functionality of psychotherapy for bipolar disorder, we developed LiveWell, a smartphone-based self-management intervention. Unfortunately, many mental health technology interventions suffer from high attrition rates with users rapidly failing to maintain engagement with the intervention technology. Human support reduces this commonly observed engagement problem but does not consistently improve clinical and recovery outcomes. To facilitate ongoing efforts to develop human support for digital mental health technologies, this paper describes the design decisions, theoretical framework, content, mode, and timing of delivery, as well as the training and supervision for coaching support of the LiveWell technology. This support includes three clearly defined and structured roles that aim to encourage use of the technology, self-management strategies, and communication with care providers. A clear division of labor is established between the coaching support roles and the intervention technology to allow lay personnel to serve as coaches and thereby maximize accessibility to the LiveWell intervention.
... It describes the planning process of health promotion in six steps: 1. needs assessment 2. creating the matrix of goals for behavior change 3. choosing theory-based approaches and practical strategies 4. developing interventions 5. planning the implementation of program 6. planning the evaluation [16]. In other studies, IM has been used successfully to determine and implement behavioral and environmental interventions in cigarette smoking and substance use control [17][18][19]. ...
Article
Full-text available
Background The present study aimed to evaluate the results of a theory-based and systematic intervention on Hookah Tobacco Smoking (HTS) cessation in women local to Bandar Abbas, Iran. Methods In the present quasi-experimental research, we used an intervention mapping approach to develop, implement, and evaluate an education and training course as our intervention. Applying the results of a systematic review and two prior local qualitative studies, we identified six HTS determinants and set goals for the intervention. We selected 212 eligible women through systematic stratified random sampling and enrolled them in control and intervention groups. The course was presented to the intervention group in 17 sessions for four months. The educational material was developed to address the goals of the intervention, improve HTS determinants, and change the HTS behavior. We used a questionnaire to collect data on participants’ characteristics, HTS behavior, and detailed determinants of HTS in the control and intervention groups at the beginning of the study, at the end of the intervention, and at three- and six- months follow-up. All work done in the study was guided by ethical considerations. Results The results showed no significant difference between women enrolled in control and intervention groups regarding participants’ characteristics and HTS behavior. At baseline, there were no differences between groups for six determinants of HTS (knowledge, attitude, social norms, self-efficacy, habit, and intention). At the end of the intervention and at three and six months follow-up, the women in the intervention group had significantly better results in all six domains, compared with those in the control group. The rate of HTS abstinence at the end of the intervention and at the three- and six-month follow-ups was 61.3%, 48.5%, and 45.5% for the intervention and 16%, 14.4%, and 10% for the control groups, respectively. Conclusions HTS is a complicated behavior, and its cessation is hard. However, Intervention Mapping (IM) can be a powerful integrative, purposeful, theory-based, and participation-based method to reduce or cease HTS. This method should be tested in other settings. Trial registration : IRCT20190126042494N1, Registered 3.3.2019. https://en.irct.ir/trial/37129
... To address the need for increased access to and enhancement of empirically supported tools and content for individuals with bipolar disorder, a novel smartphone-based self-management intervention (LiveWell) has been developed (NCT02405117) and tested in a single-blind randomized controlled trial (NCT03088462). Because adequate description of interventions is essential to facilitate ongoing efforts to improve and disseminate empirically supported treatments [53][54][55][56], the adaptive components (decision points, tailoring variables, decision rules, mode, and content of delivery options) for the LiveWell intervention are described here. The overall intervention framework and design for LiveWell, including the delivery and timing of the fixed content and the evaluation methodology, are described in detail elsewhere [57]. ...
Article
Full-text available
Background: Bipolar disorder is a severe mental illness that results in significant morbidity and mortality. While pharmacotherapy is the primary treatment, adjunctive psychotherapy can improve outcomes. However, access to therapy is limited. Smartphones and other technologies can increase access to therapeutic strategies that enhance self-management while simultaneously augmenting care by providing adaptive delivery of content to users as well as alerts to providers to facilitate clinical care communication. Unfortunately, while adaptive interventions are being developed and tested to improve care, information describing the components of adaptive interventions is often not published in sufficient detail to facilitate replication and improvement of these interventions. Objective: To contribute to and support the improvement and dissemination of technology-based mental health interventions, we provide a detailed description of the expert system for adaptively delivering content and facilitating clinical care communication for LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder. Methods: Information from empirically supported psychotherapies for bipolar disorder, health psychology behavior change theories, and chronic disease self-management models was combined with user-centered design data and psychiatrist feedback to guide the development of the expert system. Results: Decision points determining the timing of intervention option adaptation were selected to occur daily and weekly based on self-report data for medication adherence, sleep duration, routine, and wellness levels. These data were selected for use as the tailoring variables determining which intervention options to deliver when and to whom. Decision rules linking delivery of options and tailoring variable thresholds were developed based on existing literature regarding bipolar disorder clinical status and psychiatrist feedback. To address the need for treatment adaptation with varying clinical statuses, decision rules for a clinical status state machine were developed using self-reported wellness rating data. Clinical status from this state machine was incorporated into hierarchal decision tables that select content for delivery to users and alerts to providers. The majority of the adaptive content addresses sleep duration, medication adherence, managing signs and symptoms, building and utilizing support, and keeping a regular routine, as well as determinants underlying engagement in these target behaviors as follows: attitudes and perceptions, knowledge, support, evaluation, and planning. However, when problems with early warning signs, symptoms, and transitions to more acute clinical states are detected, the decision rules shift the adaptive content to focus on managing signs and symptoms, and engaging with psychiatric providers. Conclusions: Adaptive mental health technologies have the potential to enhance the self-management of mental health disorders. The need for individuals with bipolar disorder to engage in the management of multiple target behaviors and to address changes in clinical status highlights the importance of detailed reporting of adaptive intervention components to allow replication and improvement of adaptive mental health technologies for complex mental health problems.
... LiveWell, a novel smartphone-based self-management intervention for bipolar disorder, has been developed (NCT02405117) and is being tested in a single-blind RCT (NCT03088462). Because adequate description of interventions is essential to facilitate ongoing efforts to improve and disseminate empirically supported treatments [56][57][58][59], the theoretical and empirically supported framework, design, content, mode and timing of delivery, as well as the evaluation methodology for LiveWell is described here. ...
Preprint
BACKGROUND Bipolar disorder is a severe mental illness with high levels of morbidity and mortality. Even with pharmacologic treatment, frequent recurrence of episodes, long episode durations, and persistent inter-episode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes, but access to therapy is limited and many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, application use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder which can then be utilized to support ongoing improvement of treatment. OBJECTIVE To facilitate the ability to replicate, improve, implement and disseminate effective interventions for bipolar disorder, we provide a description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial of LiveWell: a smartphone-based self-management intervention for individuals with bipolar disorder. The goal of this trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden, while simultaneously elucidating behavioral targets of the intervention and better characterizing bipolar disorder course and treatment response. METHODS The study is a single blind randomized controlled trial (N = 205, 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is time to relapse. Secondary outcomes are percent time symptomatic, symptom severity, and quality of life. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, application use and personalized content will be created with the aim of better predicting treatment response and relapse risk. RESULTS Recruitment and screening started in March 2017 and ended in April 2019. Follow up ended April 2020. The study results are expected to be published in 2021. CONCLUSIONS This study will examine the potential of LiveWell for reducing relapse risk and symptom burden in individuals with bipolar disorder by increasing access to empirically supported self-management strategies. Simultaneously, a database will be created to initiate development of algorithms to personalize and improve treatment for bipolar disorder. Additionally, we hope that the description of the theoretical and empirically supported framework, intervention design, and study protocol for the randomized controlled trial of LiveWell provided here will facilitate the ability to replicate, improve, implement and disseminate effective interventions for bipolar disorder. CLINICALTRIAL ClinicalTrials.gov NCT03088462
... IM emphasizes the importance of a social ecological approach to behavioral change, and is useful for identifying individual and environmental determinants and selecting appropriate intervention methods and strategies to address the identified determinants [16,21]. IM has been deployed to promote specific health behaviors such as physical activity enhancement, checkups for cancer prevention, diet management, and smoking cessation [22][23][24][25], and its effectiveness has also been demonstrated for comprehensive health behavior intervention programs such as chronic disease self-management programs [26,27], and reproductive health management [28,29]. In light of the increasing need for preconception healthcare for women with IBD in Korea [4], we planned to develop a preconception care program for women with IBD in Korea using the IM protocol. ...
Article
Full-text available
The prevalence of inflammatory bowel disease in Korea is rapidly increasing. Women with inflammatory bowel disease have a higher risk of adverse birth outcomes than healthy women, and the magnitude of this risk is related to the severity of the disease at the time of pregnancy. For a woman with inflammatory bowel disease to have a healthy pregnancy, interventions are needed to manage the disease before pregnancy—implying a need for pregnancy planning. In this study, the intervention mapping protocol was used to develop a program for this purpose. This protocol contains the following stages: needs assessment, setting of program outcomes and performance objectives, selection of methods and strategies based on theory, and development of the program and its materials. Through individual in-depth interviews and a literature review, individual and environmental determinants were assessed and six change objectives of the program were set. The methods and practical strategies were developed based on the information-motivation-behavioral skills model, self-efficacy theory, and social support theory. The final program, consisting of four sessions and the corresponding materials, was completed by making revisions based on a content validity assessment by experts and a pilot test. Follow-up studies on the implementation of this program will be conducted in the future.
Article
Background: Bipolar disorder is a severe mental illness with high morbidity and mortality rates. Even with pharmacological treatment, frequent recurrence of episodes, long episode durations, and persistent interepisode symptoms are common and disruptive. Combining psychotherapy with pharmacotherapy improves outcomes; however, many individuals with bipolar disorder do not receive psychotherapy. Mental health technologies can increase access to self-management strategies derived from empirically supported bipolar disorder psychotherapies while also enhancing treatment by delivering real-time assessments, personalized feedback, and provider alerts. In addition, mental health technologies provide a platform for self-report, app use, and behavioral data collection to advance understanding of the longitudinal course of bipolar disorder, which can then be used to support ongoing improvement of treatment. Objective: A description of the theoretical and empirically supported framework, design, and protocol for a randomized controlled trial (RCT) of LiveWell, a smartphone-based self-management intervention for individuals with bipolar disorder, is provided to facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar disorder. The goal of the trial is to determine the effectiveness of LiveWell for reducing relapse risk and symptom burden as well as improving quality of life (QOL) while simultaneously clarifying behavioral targets involved in staying well and better characterizing the course of bipolar disorder and treatment response. Methods: The study is a single-blind RCT (n=205; 2:3 ratio of usual care vs usual care plus LiveWell). The primary outcome is the time to relapse. Secondary outcomes are percentage time symptomatic, symptom severity, and QOL. Longitudinal changes in target behaviors proposed to mediate the primary and secondary outcomes will also be determined, and their relationships with the outcomes will be assessed. A database of clinical status, symptom severity, real-time self-report, behavioral sensor, app use, and personalized content will be created to better predict treatment response and relapse risk. Results: Recruitment and screening began in March 2017 and ended in April 2019. Follow-up ended in April 2020. The results of this study are expected to be published in 2022. Conclusions: This study will examine whether LiveWell reduces relapse risk and symptom burden and improves QOL for individuals with bipolar disorder by increasing access to empirically supported self-management strategies. The role of selected target behaviors (medication adherence, sleep duration, routine, and management of signs and symptoms) in these outcomes will also be examined. Simultaneously, a database will be created to initiate the development of algorithms to personalize and improve treatment for bipolar disorder. In addition, we hope that this description of the theoretical and empirically supported framework, intervention design, and study protocol for the RCT of LiveWell will facilitate the ability to replicate, improve, implement, and disseminate effective interventions for bipolar and other mental health disorders. Trial registration: ClinicalTrials.gov NCT03088462; https://www.clinicaltrials.gov/ct2/show/NCT03088462. International registered report identifier (irrid): DERR1-10.2196/30710.
Article
Full-text available
Background Bipolar disorder is a serious mental illness that results in significant morbidity and mortality. Pharmacotherapy is the primary treatment for bipolar disorder; however, adjunctive psychotherapy can help individuals use self-management strategies to improve outcomes. Yet access to this therapy is limited. Smartphones and other technologies have the potential to increase access to therapeutic strategies that enhance self-management while simultaneously providing real-time user feedback and provider alerts to augment care. Objective This paper describes the user-centered development of LiveWell, a smartphone-based self-management intervention for bipolar disorder, to contribute to and support the ongoing improvement and dissemination of technology-based mental health interventions. Methods Individuals with bipolar disorder first participated in a field trial of a simple smartphone app for self-monitoring of behavioral targets. To develop a complete technology-based intervention for bipolar disorder, this field trial was followed by design sessions, usability testing, and a pilot study of a smartphone-based self-management intervention for bipolar disorder. Throughout all phases of development, intervention revisions were made based on user feedback. ResultsThe core of the LiveWell intervention consists of a daily self-monitoring tool, the Daily Check-in. This self-monitoring tool underwent multiple revisions during the user-centered development process. Daily Check-in mood and thought rating scales were collapsed into a single wellness rating scale to accommodate user development of personalized scale anchors. These anchors are meant to assist users in identifying early warning signs and symptoms of impending episodes to take action based on personalized plans. When users identified personal anchors for the wellness scale, the anchors most commonly reflected behavioral signs and symptoms (40%), followed by cognitive (25%), mood (15%), physical (10%), and motivational (7%) signs and symptoms. Changes to the Daily Check-in were also made to help users distinguish between getting adequate sleep and keeping a regular routine. At the end of the pilot study, users reported that the Daily Check-in made them more aware of early warning signs and symptoms and how much they were sleeping. Users also reported that they liked personalizing their anchors and plans and felt this process was useful. Users experienced some difficulties with developing, tracking, and achieving target goals. Users also did not consistently follow up with app recommendations to contact providers when Daily Check-in data suggested they needed additional assistance. As a result, the human support roles for the technology were expanded beyond app use support to include support for self-management and clinical care communication. The development of these human support roles was aided by feedback on the technology's usability from the users and the coaches who provided the human support. Conclusions User input guided the development of intervention content, technology, and coaching support for LiveWell. Users valued the provision of monitoring tools and the ability to personalize plans for staying well, supporting the role of monitoring and personalization as important features of digital mental health technologies. Users also valued human support of the technology in the form of a coach, and user difficulties with aspects of self-management and care-provider communication led to an expansion of the coach's support roles. Obtaining feedback from both users and coaches played an important role in the development of both the LiveWell technology and human support. Attention to all stakeholders involved in the use of mental health technologies is essential for optimizing intervention development.
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I: Background.- 1. An Introduction.- 2. Conceptualizations of Intrinsic Motivation and Self-Determination.- II: Self-Determination Theory.- 3. Cognitive Evaluation Theory: Perceived Causality and Perceived Competence.- 4. Cognitive Evaluation Theory: Interpersonal Communication and Intrapersonal Regulation.- 5. Toward an Organismic Integration Theory: Motivation and Development.- 6. Causality Orientations Theory: Personality Influences on Motivation.- III: Alternative Approaches.- 7. Operant and Attributional Theories.- 8. Information-Processing Theories.- IV: Applications and Implications.- 9. Education.- 10. Psychotherapy.- 11. Work.- 12. Sports.- References.- Author Index.