Process and outcome evaluation of the“No more smoking!It’s time for physical activity”program

Mary Hassandra*,Nikos Zouranos,Georgia Kofou,Konstantinos Gourgoulianis, Yiannis Theodorakis

aFaculty of Sport and Health Sciences,Department of Sport Sciences,University of Jyva¨skyla¨,P.O.Box 35,Jyva¨skyla¨40014,Finland

bDepartment of Physical Education and Sport Sciences,University of Thessaly,Karies,Trikala 42100,Greece

cDepartment of Medicine,School of Health Sciences,University of Thessaly,Viopolis,Larissa 41110,Greece

Process and outcome evaluation of the“No more smoking!It’s time for physical activity”program

Mary Hassandraa,*,Nikos Zourbanosb,Georgia Kofoub,Konstantinos Gourgoulianisc, Yiannis Theodorakisb

aFaculty of Sport and Health Sciences,Department of Sport Sciences,University of Jyva¨skyla¨,P.O.Box 35,Jyva¨skyla¨40014,Finland

bDepartment of Physical Education and Sport Sciences,University of Thessaly,Karies,Trikala 42100,Greece

cDepartment of Medicine,School of Health Sciences,University of Thessaly,Viopolis,Larissa 41110,Greece

Purpose:The aim of this study was to evaluate the program“No more smoking!It’s time for physical activity”,with a mixed methods design,in order to collect information to improve the program for future applications.

Methods:Forty patients across five anti-smoking clinics in Central Greece completed the program.Counselors’records and participants’questionnaires and interviews were used as data in order to evaluate the programs’process and outcome.

Results:Quantitative measures before and after the program revealed significant differences on smoking behavior,physical activity(PA) behavior,self-efficacy,and smoking habit measures.Qualitative data implied that the promotion of PA as a cessation aid was perceived as positive by the participants and both participants’and counselors’statements were encouraging for the effectiveness of PA promotion during the program as a cessation-aid technique.

Conclusion:Evaluation of the“No more smoking!It’s time for physical activity”program showed encouraging results.People who try to quit smoking can become more physically active through targeted intervention and they regard PA as a significant aid in their efforts to quit smoking.

Copyright?2013,Shanghai University of Sport.Production and hosting by Elsevier B.V.All rights reserved.

Counseling;Evaluation;Greek adults;Physical activity;Smoking cessation

1.Introduction

Therelationshipbetweensmokingandphysicalactivity(PA) appears to be quite complex.1Although some studies found no or a weak relationship,2the majority of recent studies show an inverserelationshipbetweenPAandsmoking.3,4Astudywithin theGreekpopulationexaminedsmokinghabitsinrelationtoPA. Results revealed that the more physically active people are the lesstheysmoke,5andtheseresultscontributetotheprospectthat PAisinverselyrelatedtothehabitofsmoking.Thepromotionof PA has the potential to become an aid strategy6regarding smoking cessation programs.Review studies summarising relevantresultsshowthatthereisapositiveassociationbetween initiating an attempt to quit smoking and engagement in PA1,7and patients who prepared themselves to stop smoking were more likely to increase their PA rates.8The promotion of PA is considered as a low-cost strategy for health care providers as they aid individuals to quit smoking.9

Both smokers10and smoking cessation counselors11have highlighted the use of PA as a valuable smoking cessation aid. Haddock et al.10examined beliefs of 36,012 young adults about potential risk reduction strategies for smokers.This 1-year longitudinal survey found that participants rated diet,PA,and low-yield cigarettes as providing the most healthy benefits regardless of their smoking status.Everson-Hock et al.11interviewed 11 trained smoking cessation advisors who promoted PA to their clients.Findings show that PA is a useful and easily performed cessation aid rather than a new behavior that has to be acquired,which might increase the sense of load/pressure to patients.They also suggested that PA could be promoted as a cessation aid and as part of a holistic lifestyle change consistent with a non-smoker’s identity.Finally,advisors asserted that it is important to focus on the needs and capabilities of individual clients.Nademin et al.12collected both quantitative(questionnaires)and qualitative (focus group)data from 43 young college women.Participants reported that successful cessation interventions must include PA components,group-based meetings,eating tips,reminders of drawbacks to smoking,and use of technology.

PAmay aid insmokingcessationbyaddressingphysiological and psychosocial issues.Regular PA increases caloric expenditure,and therefore may increase metabolic rate and reduce the weight increase associated with smoking cessation.13—15Several smoking cessation interventions,from computer-generatedtailoredletterstointensivegroup-basedinterventions,which triedtohelpsmokersstrengthentheirself-efficacytoabstainfrom smoking,had promising results indicating that self-efficacy can beincreasedusingarangeofmethodsincludingPApromotion.16

In the international literature,the integration of PA promotion as a cessation aid has been well perceived by the patients of a smoking cessation clinic.In Greece,where the never exercisers and regular smokers’percentages are amongst the higher in Europe,smokers might not be so receptive to a program that integrates these two behaviors.17Therefore,a smoking cessation counseling program,named“No more smoking!It’s time for physical activity”,that incorporates PA promotion as an additional quitting aid has been developed and pilot tested.The initial evaluation report18showed that 18 patients,from the 40 who completed the program,succeeded to increase their PA level during the program and managed to quit smoking for 1 year after the program.The description of the program and the early preliminary results have been published,18whereas,the purpose of this paper was to present the subsequent results from the additional measures that were tracking the program’s applicability and effectiveness.The early preliminary results showed that the percentage of those who succeeded to quit smoking for 1 year was 45%of those who completed the program(18/40).The increase of the PA levels among the successful quitters was much higher than the non-successful quitters.18Subsequently,for the purpose of the present study,additional data were collected and analyzed to further evaluate the programs’process and outcome(applicability and effectiveness of the program).

2.Methods

2.1.Evaluation procedure

The research method that is often preferred in process and outcome evaluation relies on mixed methods design.19A triangulation mixed methods design was followed in this study and both qualitative and quantitative data were collected, analyzed separately and findings were combined in the discussion section.20The process evaluation provides information about what and what does not work in a program.Such information explains how a program operates and clarifies the program improvement requirements.The current process evaluation focused on how the integration of PA promotion was perceived by the counselors and the participants in relation to their efforts to quit smoking.Information for process evaluation was collected through the counselors’diaries and records during the intervention and through the participants’interviews at the end of the program.The outcomes evaluation provides information on whether a program has reached its aims.The current outcome evaluation focused on examining a) if significant differences on the following measures occurred: smoking behavior(pre-,post-,and follow-up),PA behavior (pre-,post-),self-efficacy(pre-,post-)and habit(pre-,post-), and b)participants’perceptions on the effectiveness of the integration of PA in the smoking cessation program.Information for the outcomes evaluation was collected through questionnaires assessing the targeted behaviors(smoking and PA),psychological variables(habit and self-efficacy)before and after the program,and the participants’interviews at the end of the intervention.Additional participants’quantitative data were collected 3,6,and 12 months after the end of the program in order to estimate if the main outcome of the program(quitting smoking)had long-term effects.

2.2.Participants

Fifty adult patients from five anti-smoking clinics in the central Greece region were initially enrolled in the program. Ten participants did not finish the program.The remaining 40(12 men and 28 women)(mean age:45.6 years old) completed the intervention.The ethics committee of the University of Thessaly approved the study and all participants signed consent forms for participation.

2.3.Measures

2.3.1.Quantitative

Participants completed all the quantitative measures before and after the end of the intervention program.

(1)Self-efficacy.Individual’s confidence to abstain from smoking in a variety of different situations was assessed using a 9-item21self-report measure of self-efficacy(e.g., how confidentiam thatiwould not smoke,whenifirst get up in the morning).Responses were given on a 5-point scale,which were anchored by“Not at all confident”=1 to“Extremely confident”=5.An overall score of individual’s confidence to abstain from smoking was calculated.

(2)Smoking habit.The habit of smoking cigarettes was measured with a 12-item Self-Report Habit Index,22which was slightly adapted in order to accommodate the presentbehavior(e.g.,smoking is somethingiwould find hard not to do).Responses were given on a 7-point scale,which were anchored by“Disagree completely”=1 to“Agree completely”=7.Higher scores indicated a stronger habit.

(3)PA behavior.PA was assessed by the self-reported questionnaire of Godin and Shephard.23The questions assess the strenuous,moderate,and light PAs for more than 15 min during 1 week.Reported frequencies of strenuous, moderate,and light activities were multiplied by nine,five, and three,respectively.The total weekly leisure activity was calculated by summing the products of the separate components: total leisure activity score=(9×strenuous)+(5×moderate)+(3×light).

(4)Smoking behavior.Participants answered the question,“How many cigarettes did you smoke yesterday?”The cigarettes smoked per day were used as the smoking behavior variable.

(5)Social desirability.Participants also completed the short version of the Crowne and Marlowe24Social Desirability Scale after the intervention,to control positively biased responses.Correlations between each measure and the social desirability scores were all non-significant(Table 1).

2.3.2.Qualitative data collection

(1)Interviews.Interviews were conducted in a semi-structured format,providing depth through probe questions.25Participants answered orally questions regarding their experiences from being physically active as a cessation aid within the counseling program that they attended.Two trained qualitative researchers conducted all interviews. Each interview lasted from 35 to 45 min for each participant and was conducted after appointments in a quiet room setting.Each interview was recorded and later transcribed verbatim.

(2)Counselors’diaries.Counselors assigned to the program kept records and detailed diaries of individual meetings with each participant.They recorded the procedure and kept detailed field notes with comments on issues that arose during the sessions.All PA related notes were then analysed to identify emerging themes.

(3)Qualitative data analysis.A content analysis“at the end”26was conducted with the assistance of two peer de-briefers. Data analysis was carried out both inductively and deductively.Inthefirstinductivestep,bothtranscribedinterviews and counselors’diaries were used to identify raw data passages answering the process and outcome main evaluation questions.In the second step,a deductive approach was used;generationandcategorisationofthemesemergedfrom participants’answers.In the third step,an evaluation of themes was conducted.27Trustworthiness of the qualitative procedure was enhanced through the following five strategies:281)Prolonged engagement was attained by the involvement of three of the five researchers of this study as counselors and PA facilitators.They all spent time in the 10 treatment sessions and developed relationships and rapport with the participants in order to build trust.During this interaction it was also possible to identify the most relevant characteristicsandelementsasawaytoattaindepththrough 2)persistent observation.3)Member checking was carried outaftertheinterviews.Eachparticipantwasaskedtoverify his/herinterviewbyreadingthetranscription2—5daysafter the interview had been conducted.In order to achieve 4) inquiry audit,an external researcher,familiar with qualitative research,evaluated whether or not the findings,interpretations and conclusions were supported by the qualitative data.Finally,the use of multiple data collectors andmultipleanalystscontributedtotheunderstandingofthe phenomenon under investigation 5)analyst triangulation.

3.Results

3.1.Quantitative results

3.1.1.Preliminary analysis

Means±SD andcorrelations ofvariables thatwere assessed immediately after the intervention are presented in Table 1.All scales showed adequate internal consistencies(α coefficients ranging from 0.84 to 0.93).More specifically,correlation analyses revealed negative low relationships between number of cigarettes after the intervention for self-efficacy(r=-0.27,p=0.09)and exercise behavior(r=-0.20,p=0.22),and positive moderate relationship with habit(r=0.35,p＜0.05). Mean±SD of the number of cigarettes as reported by the participants(n=40)by time are the following:before the intervention=17.38± 12.84,after the intervention=3.80±7.71,3 months after the intervention=4.43±9.39,6 monthsaftertheintervention=4.43±9.36,and12monthsafter the intervention=5.55±10.11.

Table 1 Means±SD and correlations for all variables.

3.1.2.Main analysis

Kolmogorov—Smirnov tests were used to see if the distributions of the number of cigarettes before,immediately after, 3,6,and 12 months after the intervention significantly differed from a normal distribution.The results revealed that the number of cigarettes before,D(40)=0.21,p＜ 0.001, immediately after,D(40)=0.44,p＜0.001,3 months,D(40)=0.43,p＜0.001,6 months,D(40)=0.41,p＜0.001, and 12 months after the intervention,D(40)= 0.38,p＜0.001,were significantly not normal.Friedman’s analysis of variance(ANOVA)test showed that the number of cigarettessignificantly changed overtime χ2(4)= 47.21,p＜0.001.Wilcoxon tests were used to follow-up this finding using the Bonferroni correction and all effects were reported at a 0.005 level of significance.It appeared that the number of cigarettes decreased significantly immediately after the end of the intervention (Z= -4.66,p＜ 0.001),3 months (Z=-4.54,p＜0.001),6 months(Z=-4.47,p＜0.001), and 12 months(Z=-4.34,p＜0.001)after the intervention. There were no significant differences between the post measure and the follow-up measures(3,6,and 12 months).

Totestfordifferencesbeforeandaftertheintervention,inselfefficacy,habit of smoking,total leisure activity,light,moderate, and strenuous exercise,repeated measures multivariate analysis of variance(MANOVA)was performed.The analysis revealed significant multivariate effect,F(5,35)=17.76,p＜ 0.001, η2=0.72,observedpower=1.00.Examinationoftheunivariate effects revealed significant differences for self-efficacy,habit of smoking,total leisure activity,light exercise,moderate exercise andforstrenuousexercise(Table2).Examinationofthepairwise comparisons using Bonferroni adjustment and the means revealed that immediately after the intervention self-efficacy improved(p＜ 0.001),the habit of smoking decreased (p＜0.001),total leisure activity,light exercise,moderate exercise,and strenuous exercise increased(allp＜0.001).

3.2.Qualitative results

The two main predetermined axes of all the qualitative data analysis were guided by two main research questions:1)How the integrated technique of PA promotion was perceived by theparticipants?(indicating the process evaluation)and 2)How effective this integration was?(indicating the outcome evaluation of the program).Under these two main research questions the data were further categorised and the themes that emerged are presented in Table 3.A descriptive overview of the emerging themes follows.

Table 2 Repeated measures analysis of variance.

3.2.1.Process evaluation:participants’perceptions of the integration of PA

The emerging themes showed that participants perceived the integration of PA as a means to improve their health and as a way to develop a new identity.They saw PA as a way to manage their stress and tension,which derived from the withdrawal symptoms from cigarette cravings.There were several comments indicating that the more they managed to increase their PA levels the less they wanted to smoke.They highlighted the benefits of exercise on their own body and contrasted these benefits with the negative effects of smoking on their body.There were also comments showing that when they planned to attend the scheduled exercise sessions they did not want to smoke beforehand because they realised that this would lower their performance.In addition,they pointed out that their desire to smoke after exercise decreased from session to session.Participants also linked their increased PA to increased awareness of other health-related behaviors,such as diet quality and alcohol consumption.

3.2.2.Outcome evaluation:participants’and counselors perceptions on the effectiveness of PA integration

The findings show that a wide range of PAs from non-exercise PAs(e.g.,walking)to leisure time sports(e.g.,basketball),contributed to the programs’effectiveness.No matter the type of PA participants perceived these activities as helpful to their efforts to quit.More frequent and longer support was necessary for some patients,according to comments both from counselors and participants.Tracking PA through pedometers was helpful and motivating,but not for all of the participants. The program provided skills training on how to resist tempting situations,however some participants suggested PAs(e.g., breathing exercises)during tempting situations in social environments were not effective.Counselors’suggestions for future program applications showed that PA promotion was helpful but the promotion of a healthier lifestyle,in general (including e.g.,alcohol and healthy eating),might also be helpful for some patients.The addition of some group counseling sessions to the individual ones has been suggested as a potential helpful strategy.Finally,a follow-up period with any kind of communication has been suggested as essential in order to help patients maintain new behaviors.

4.Discussion

Both quantitative and qualitative results were encouraging. The participants of the program significantly decreased the number of cigarettes they smoked by the end of the intervention.Additionally,they increased their self-efficacy to abstain from smoking and decreased their smoking habitscores compared to their initial scores before they enrolled in the program.Increased confidence in one’s ability to abstain from smoking is considered both a predictor and possible determinant of smoking cessation.29

Table 3 Emerging themes and quotes.

Qualitative information indicated that,in general,patients perceived PA as a valuable additional cessation aid to the counseling program.Regarding the increase of PA,results indicate that participants who increased their PA had better quit smoking rates after 1 year.This trend is in line with previous findings8,30suggesting that smoking cessation rates are higher among those who are more physically active.According to what participants stated,PA was used as a way to control their stress and anxiety and as a means to deal with the fear of weight gain associated with smoking cessation.Both of these benefits of PA during smoking cessation programs have been extensively reported by other researchers.11,31According to Landers,32PA helps deal with stress and can thus satisfy the motives of those who say that they smoke to control feelings of anxiety.Additionally,people who are physically active report fewer symptoms of depression,33so PA can possibly act as a substitute for smokers who use cigarettes in order to cope with feelings of depression.

PA as a cessation aid was also seen as part of a holistic lifestyle change.Participants of the present study found PA as a way to improve their life by adopting a healthier lifestyle. Similar results have been found by the qualitative study of Everson-Hock et al.11that identified the lifestyle change as one of the“benefits”related to implementing PA into smoking cessation practice.

Another interesting finding is that PA was considered beneficial to some participants,as a mechanism of attention distraction,in order to avoid relapse.Even participants who did not manage to quit smoking and did not follow the PAs of the program managed to make some changes to everyday PAs (e.g.,use of bicycle and stairs instead of elevator).According to deRuiter and Faulkner,31“Increases in physical activity, even in the absence of successful smoking cessation,should be seen as a positive outcome in cessation interventions”.

There were participants,new to PA,who realised their poor physicalconditionandhowthiscanbechangedbydecreasingor quitting smoking.In addition,participants became aware of their physical capability as they increased their PA,in a relativelyshorttime.Nevertheless,theaimofthePApromotionwas not necessarily the fitness improvement,but the willingness tocontinue PA.15Counseling techniques and goal setting also helped participants in organising their everyday life activities anddirectedthemtoparticipateinPAasatechniquetodealwith thedesireforsmokingandstress,astheyreported.Accordingto theliterature,exerciseparticipationduringtheperiodoftobacco withdrawal also helps patients deal with sleeping problems,34concentration,35and depression.36

Most of the participants imagine their future selves as nonsmokers and physically active.This implies that the program helped them to start building a new,healthier identity.According to several researchers,becoming more physically active may serve as a‘‘gatekeeping’’function,increasing the likelihood of subsequent smoking cessation attempts.8,31This function seems to be apparent to the present participants through their statements on how they think and feel immediately before and after their exercise sessions.

Regarding the kind of PA that was more helpful for them in their effort to quit during the program,the majority of the participants mentioned jogging as the most convenient way. However a rich variety of other activities were also mentioned reflecting the need for a program to allow participants to choose what is most convenient for them.

Monitoring PA through pedometers was not very popular. There were some participants who found it useful but most of them did not find it convenient,because they had to use it for 10 weeks.Those who perceived the pedometer as useful reported that it provided feedback and helped them set goals for increasing their PA levels and kept them motivated.In future applications of the intervention,it might be more helpful to give participants a choice to use the pedometer either on the first and last week of the intervention or during all 10 weeks.

Additionally,to further improve the program participants were suggested using short message service motivational messages for follow-up support.Counselors suggested using group activities during meetings and during the PAs provided by the program.Finally,some participants requested that additional resistance tips or skills be included in the program,for example on how to resist on a social interaction with other smokers.This suggestion implies that the program needs to make some improvements in skills training also.The integration of communication technology applications may be one way to further improve this component of the program.

The main limitation of the current study is the lack of a control group to test if the integration of PA promotion into the counseling program made it more effective.Additionally,the present study relies on self-reports(higher risk of bias)which is a concern for the internal validity.Nevertheless,the information gained from this program application is considered valuable for further applications in the future with a control trial method.Another limitation of the current study is that only the smoking behavior and not the PA adherence has been tracked through the follow-up measures.Future longitudinal studies,with both quantitative and qualitative data collection, following both of the patients’behavioral patterns,will provide us with a deeper understanding on the underlying mechanisms of this behavior change procedure.Further research is needed to enhance our knowledge and practice of the promotion of PA as an additional aid to quitting smoking. Multidisciplinary approaches in research could give valuable information to improve practice for example,integrating strategies from different disciplines such as health behavior, social behavior,and behavioral economics.

5.Conclusion

In conclusion,the evaluation of the“No more smoking!It’s timeforphysicalactivity”programshowedencouragingresults. The smoking cessation counseling program with integration of PA promotion had both short and long-term positive results on the participants’efforts to quit smoking.Quantitative data showedthattheprogramboostedtheparticipants’confidenceto abstain from smoking in a variety of different situations and decreased their smoking habit and behavior.Additionally, qualitative data yielded valuable information related to the experiences of participants and how they experience the integrationofPAasacessationaid.Peoplewhotrytoquitsmokingcan become more physically active through targeted intervention. Atthesametimesmokers,themselves,regardPAasasignificant aid in their efforts to quit smoking.

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1 October 2012;revised 28 January 2013;accepted 20 May 2013

*Corresponding author.

E-mail address:maria.m.chasandra@jyu.f i(M.Hassandra)

Peer review under responsibility of Shanghai University of Sport

2095-2546/$-see front matter Copyright?2013,Shanghai University of Sport.Production and hosting by Elsevier B.V.All rights reserved. http://dx.doi.org/10.1016/j.jshs.2013.06.001