Delivering smoking cessation support to disadvantaged groups: a qualitative study of the potential of community welfare organizations

Suitability of smoking cessation support from social and community service organizations: perspectives of Dutch clients

Social and community service organizations (SCSOs) may be a promising new environment to more successfully reach people with a lower socioeconomic position (SEP) for smoking cessation support. However, studies that investigate clients' perspectives of the suitability of SCSOs as a setting to discuss smoking are scarce. This study aimed to (i) investigate the suitability of smoking cessation support provided by SCSOs, according to people with a low SEP, and (ii) explore their reasons for considering it suitable or unsuitable. Semi-structured interviews were conducted with 19 individuals with a low SEP who smoked regularly (N = 14) or had smoked regularly (N = 5). They have been in contact with SCSOs in a specific neighborhood in Amsterdam. Data were analyzed using a thematic approach. Participants generally considered SCSOs as suitable for providing smoking cessation support, as professionals are involved, build a relationship of trust, and offer personalized and holistic support. SCSOs are located nearby and familiar, they provide support in both group and individual settings and might offer additional supportive (group)activities. A number of participants expressed doubts about the waiting time for support, the fact that the needed support might exceed professionals' expertise, and the lack of aftercare. SCSOs can be an additional opportunity for providing smoking cessation support that aligns with the circumstances of lower SEP people. To harness the potential, smoking cessation could be integrated into education programs and training among professionals could be promoted. Policy changes within and outside SCSOs would be needed.

Smoking Cessation Support in Social and Community Service Organizations: Potential Activities, Barriers, and Facilitators

INTRODUCTION

Social and Community Service Organizations (SCSOs) are a potential setting to reach and support people with a low socioeconomic position who smoke, yet smoking cessation is not widely supported by SCSO professionals.

AIMS AND METHODS

This study aims to identify SCSO professionals' (1) potential activities to support smoking cessation and (2) barriers and facilitators in undertaking these activities. Between July and November 2022, semi-structured interviews were conducted with 21 professionals recruited through SCSOs in Amsterdam North, including participation workers, welfare workers, parent and child counselors, budget coach, debt counselor, welfare work, community sports, and community center coordinators. Data were analyzed using a thematic approach.

RESULTS

Eight activities were identified that could support the client either directly (ie, recognizing smoking clients, discussing smoking and smoking cessation, referring clients, providing smoking cessation counseling, offering help around services) or indirectly (ie, collaboration with relevant network partners, implementing smoke-free environments, enhancing professional skills). Various barriers and facilitators were identified related to the (1) client and their environment (ie, clients' readiness and social environment), (2) interaction between professional and client (ie, topic sensitivity), (3) professional (ie, professional is non-smoker, knowledge, and self-efficacy), (4) professionals' work environment (ie, necessity, responsibility, priority, and time), and (5) smoking cessation services (ie, availability of appropriate services and referral process).

CONCLUSIONS

There is potential for SCSO professionals to support smoking cessation, but several barriers hinder their efforts. To address these barriers, it is essential to take into account the factors that SCSO professionals believe facilitate the provision of smoking cessation support.

IMPLICATIONS

This study provides insight into how the potential of SCSOs in Amsterdam North to support smoking cessation efforts among people with a low socioeconomic position can be harnessed. Barriers were found at multiple levels (client, professional, client-professional interaction, and organizational) and these findings imply that stakeholders across these levels will need to prioritize smoking cessation to facilitate and stimulate SCSO professionals in supporting smoking cessation. A concrete action would be to offer SCSO professionals additional training in conversational skills to discuss smoking. As a prerequisite, easily accessible and suitable smoking cessation services should be available in the neighborhood.

Exploring the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from problematic drug or alcohol use: A qualitative systematic review

BACKGROUND

Smoking prevalence and the associated poor health and mortality is significantly higher among people with/recovering from problematic drug or alcohol (PDA) use in comparison with the general population. Evidence from existing systematic reviews shows smoking cessation enhances rather than compromises long-term abstinence from alcohol or drug use. However, these systematic reviews lack important contextual detail around the reasons why uptake of, and successful engagement with existing stop smoking services remains low for people in treatment or recovery from PDA use. This systematic review explores qualitative data on the barriers and facilitators to the uptake of smoking cessation services for people in treatment or recovery from PDA use. This key objective addresses the limited inclusion of qualitative studies in previous systematic reviews on this issue.

METHODS

A qualitative systematic review was conducted with searches across four electronic databases (PubMed, Embase, PsycINFO and Cumulative Index to Nursing and Allied Health Literature [CINAHL]). All studies that had a qualitative component about free smoking cessation/reduction programmes for people in treatment or recovery from PDA use were included. Studies that examined electronic smoking or services that required a fee were excluded. Study quality was assessed using National Institute for Health and Care Excellence checklist. Qualitative synthesis involved inductive thematic analysis. (PROSPERO Registration number: CRD42022298521).

RESULTS

8809 potentially eligible articles were identified, 72 full texts were screened and ten articles were included for full review. Barriers to uptake and engagement with existing stop smoking services centered on three key themes: perception of public health importance, programme structure, and intervention elements. Facilitators included supportive treatment environment and optimization of support/staff resources for smoking cessation service delivery.

CONCLUSION

Recommendations included influencing a change in the way people perceive the importance of smoking cessation activities during PDA use treatment or recovery. There was also some emphasis on the need to create the right environment for sustained adherence to treatment or recovery plans, and deliver the interventions within the health system as comprehensive care. The limited qualitative evidence on community-based and outpatient services highlights a research gap.

Prevalence and Factors Influencing Smoking Behavior among Female Inmates in Malaysia

BACKGROUND

Lately, smoking among adolescents is increasing despite various campaigns to address it being carried out. Previously, this habit was common among men, however, nowadays, smoking has become a habit for women as well. The purpose of this study was to determine the prevalence and its associated factors that influence smoking behavior among women inmates in Kelantan.

METHODS

A cross-sectional study was carried out among women inmates from Pengkalan Chepa Women's Prison, Kota Bharu, Kelantan. A total of 274 respondents were needed to answer a self-administered questionnaire. The data were analyzed using Multiple Logistic Regression.

RESULTS

A total of 183 participants were smokers. Women who were single and divorced had a lower chance of being influenced to smoke compared to married women. Parents with smoking habits were more associated with children who smoked compared to parents who did not smoke. A participant with secondary level education had higher odds of smoking compared to a participant with primary level education. Smoking peers significantly influenced their friends and, therefore, peer practice was a main factor influencing smoking among women inmates.

CONCLUSION

The prevalence of smoking among women inmates in Kelantan was found to be quite high. Religion (majority (90.5%) of women in the study were Muslims; it would be inappropriate to draw conclusion that religion is an influencing factor), marital status, parents' practice, peer practice and education significantly influenced women inmates to smoke.

Isolation, marginalisation and disempowerment - understanding how interactions with health providers can influence smoking cessation in pregnancy

Background

Maternal smoking during pregnancy can lead to serious adverse health outcomes for both women and their infants. While smoking in pregnancy has declined over time, it remains consistently higher in women with lower socioeconomic circumstances. Furthermore, fewer women in this group will successfully quit during pregnancy.

Aim

This study explores the barriers to smoking cessation experienced by socially disadvantaged pregnant women and investigates how interactions with health providers can influence their smoking cessation journey.

Methods

Women (either pregnant or birthed in the previous 10 years, who smoked or quit smoking in pregnancy) were recruited from a metropolitan public hospital antenatal clinic in South Australia and community organisations in surrounding suburbs. Seventeen women participated in qualitative semi-structured small focus groups or interviews. The focus groups and interviews were recorded, transcribed and thematically analysed.

Findings

Four interconnected themes were identified: 1) smoking embedded in women’s challenging lives and pregnancies, 2) cyclic isolation and marginalisation, 3) feeling disempowered, and 4) autonomy and self-determination. Themes 3 and 4 are characterised as being two sides of a single coin in that they coexist simultaneously and are inseparable. A key finding is a strong unanimous desire for smoking cessation in pregnancy but women felt they did not have the necessary support from health providers or confidence and self-efficacy to be successful.

Conclusion

Women would like improvements to antenatal care that increase health practitioners’ understanding of the social and contextual healthcare barriers faced by women who smoke in pregnancy. They seek improved interventions from health providers to make informed choices about smoking cessation and would like women-centred care. Women feel that with greater support, more options for cessation strategies and consistency and encouragement from health providers they could be more successful at antenatal smoking cessation. If such changes were made, then South Australian practice could align more with best practice international guidelines for addressing smoking cessation in pregnancy, and potentially improve outcomes for women and their children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04720-0.

Inequalities, harm reduction and non-combustible nicotine products: a meta-ethnography of qualitative evidence

BACKGROUND

We sought to review qualitative evidence on how smokers in different socioeconomic groups engage with non-combustible nicotine products (NCNP), including electronic cigarettes and nicotine replacement therapies, in order to provide insight into how these products might impact on smoking inequalities.

METHODS

We searched ten electronic databases in February 2017 using terms relating to NCNP and socioeconomic status. We included qualitative studies that were published since 1980 and were available in English. We used guidelines adapted from the Critical Appraisal Skills Programme for appraising qualitative research.

RESULTS

The review only identified studies exploring the attitudes of socioeconomically disadvantaged smokers towards NCNP for harm reduction or cessation purposes (i.e. we did not identify any relevant studies of more advantaged socioeconomic groups). Using a lines-of-argument meta-ethnographic approach, we identified a predominantly pessimistic attitude to NCNP for harm reduction or cessation of smoking due to: wider circumstances of socioeconomic disadvantage; lack of a perceived advantage of alternative products over smoking; and a perceived lack of information about relative harms of NCNP compared to smoking. Optimistic findings, although fewer, suggested the potential of NCNP being taken up among smokers experiencing socioeconomic disadvantage.

CONCLUSIONS

Overall, our review highlights the importance of considering the social, cultural and economic circumstances that influence experiences of smoking and of alternative product use.

Factors influencing the willingness of community service organisation staff to provide smoking cessation support: a qualitative study

OBJECTIVE

This study aimed to explore factors influencing community service organisation (CSO) staff members' willingness to provide tobacco cessation support to clients experiencing disadvantage.

METHODS

Face-to-face semi-structured interviews were conducted with 29 staff members from seven services in the alcohol and other drugs, homelessness, and mental health sectors in Western Australia.

RESULTS

The primary barriers to providing cessation support were believing that addressing smoking was not a priority relative to other issues, being a current smoker, and the lack of a formal tobacco cessation program within the organisation. Factors that appeared to be most influential in enabling the delivery of cessation support were organisational processes requiring staff to routinely ask clients about tobacco use, confidence to provide support, and being a past smoker.

CONCLUSIONS

The introduction of organisational procedures that include routine cessation care should be of high priority in CSOs to help reduce smoking rates among clients. Staff may also benefit from receiving training in the provision of cessation support and education about the importance and feasibility of addressing smoking concurrently with other issues. Implications for public health: The results may inform future efforts to increase the delivery of cessation care to groups of people experiencing disadvantage and comorbidity.

Receptiveness to smoking cessation training among community service organisation staff

ISSUE ADDRESSED

Smoking rates among people experiencing disadvantage are significantly higher than for the general population. Community service organisations (CSOs) have been suggested as appropriate settings to address tobacco use among this subgroup. This study aimed to (a) assess CSO staff members' interest in receiving smoking cessation training, (b) explore the factors associated with interest and (c) identify preferred cessation support information formats.

METHODS

An online survey was administered to CSO staff across Australia. Respondents were asked about the main groups targeted by their service, their role in the organisation and their interest in receiving smoking cessation training. Logistic regression analyses were used to identify factors associated with receptiveness to smoking cessation training.

RESULTS

Of the 242 CSO staff members responding to the survey, 53% were interested in receiving training. Having more frequent contact with clients and working at an organisation supporting people with a mental illness were positively associated with being interested in undertaking training. Online resources were identified as a preferred form of information relating to cessation support provision.

CONCLUSIONS

CSO staff who have frequent contact with clients may be receptive to training that would enable them to provide smoking cessation support to people experiencing disadvantage. SO WHAT?: CSOs represent an important setting for smoking cessation interventions given their existing relationship with people who have high smoking rates and the apparent receptiveness of CSO staff to participate in such initiatives.

Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review

One explanation for the increasing smoking-related health inequalities is the limited access of lower socioeconomic status (SES) smokers to smoking cessation support. In order to understand this limited access - and to eventually improve accessibility - we provide a structured overview of the barriers that lower SES smokers face in the successive phases of access to cessation support. Our literature review included 43 papers on barriers of access to cessation support for lower SES smokers, published before June 2016. We used the access to health care framework to categorize the extracted barriers into (a) either the abilities of smokers or dimensions of cessation support and (b) one of the successive phases of access to support. We found that lower SES smokers encounter many barriers. They are present in all phases of access to cessation support, and different barriers may be important in each of these phases. We also found that each phase transition is hampered by barriers related to both the abilities of smokers and the dimensions of cessation support, and that these barriers tend to interact, both with each other and with the disadvantaged living conditions of lower SES smokers. In conclusion, reducing smoking-related health inequalities by improving lower SES smokers' access to smoking cessation support requires a comprehensive approach. Our structured overview of barriers may serve as a starting point for tailoring such an approach to the multitude of barriers that prevent lower SES smokers from accessing cessation support, while simultaneously taking into account their disadvantaged living conditions.

Effectiveness of a Large, Nation-Wide Smoking Abstinence Campaign in the Netherlands: A Longitudinal Study

From 2014, the 28-day smoking abstinence campaign ‘Stoptober’ is held in the Netherlands. Each year, more than 50,000 people participate in what has become a nation-wide collective cessation attempt. This study aims to determine the short-term effects of ‘Stoptober’ on participants’ smoking behavior and behavioral determinants. Stoptober participants completed online surveys before the start of the campaign (n = 6856) and three months later (n = 1127). Descriptive statistics and t-tests were performed to determine changes in smoking and behavioral determinants. Logistic regression analyses were used to identify differences between subgroups. After three months, 71.8% of respondents had quit smoking and consumption was reduced among sustained smokers. Cessation rates were similar for subgroups by age, sex and educational level. Cessation was positively associated with confidence and self-efficacy at baseline and negatively associated with past year quit attempts and addiction level at baseline. For quitters, we found favorable changes in attitude towards cessation related stress, social norms, social pressure to smoke, self-efficacy to quit, smoking habit strength and smoker identity. For sustained smokers, we found favorable changes in attitude towards cessation related stress, self-efficacy and smoking habit strength. These results suggest that an abstinence campaign with a wide reach in a national population may be effective in decreasing smoking prevalence and cigarette consumption among a broad range of participants.

'They're Going to Smoke Anyway': A Qualitative Study of Community Mental Health Staff and Consumer Perspectives on the Role of Social and Living Environments in Tobacco Use and Cessation

Background: Addressing the high prevalence of tobacco use experienced by people with severe mental illness (SMI) requires consideration of the influence of wider cultural, socioeconomic and environmental factors. This qualitative study aimed to examine the impact of social and living environments on tobacco use and cessation by people with SMI accessing community managed mental health services. The perspectives of both staff and consumers with SMI were explored. Methods: Semi-structured focus groups were undertaken with a purposive sample of community mental health staff and consumers from three sites in three major cities in NSW, Australia. Two sites provided outreach support, and one site provided residential support. Data were collected (2017-2018) until saturation was reached. Focus groups were audio-recorded and transcribed, and thematic analysis was conducted. Results: Thirty-one staff and 17 consumers participated separately in six focus groups. Themes identified by staff included a degree of fatalism, conceptualising tobacco use as choice rather than addiction and tensions between cessation support and broader models of care. Staff viewed smoke-free home and mental health service policies as effective at promoting quitting but contradictory to recovery-oriented models of care. Consumers identified smoking as an integral part of life and social networks, as a way of maintaining control and lack of social support to quit as key themes. While many consumers reported smoking inside the home, others described enforcing smoke-free rules. Conclusion: Social and living environments played an integral role in tobacco use and cessation for both staff and consumers. The role of community managed mental health organisations in addressing tobacco use within social and living environments was not strongly supported by staff and sometimes seen as antithetical to recovery-oriented models of care. Potential ways to address this include education and training for prospective and current community mental health organisation staff highlighting the synergy between the recovery-oriented model and provision of preventive health support.

Australian mental health care practitioners' practices and attitudes for encouraging smoking cessation and tobacco harm reduction in smokers with severe mental illness

Reducing the burden of physical illness among people living with severe mental illnesses (SMI) is a key priority. Smoking is strongly associated with SMIs resulting in excessive smoking related morbidity and mortality in smokers with SMI. Smoking cessation advice and assistance from mental health practitioners would assist with reducing smoking and smoking-related harms in this group. This study examined the attitudes and practices of Australian mental health practitioners towards smoking cessation and tobacco harm reduction for smokers with SMI, including adherence to the 5As (ask, assess, advise, assist and arrange follow up) of smoking cessation. We surveyed 267 Australian mental health practitioners using a cross-sectional, online survey. Most practitioners (77.5%) asked their clients about smoking and provided health education (66.7%) but fewer provided direct assistance (31.1-39.7%). Most believed that tobacco harm reduction strategies are effective for reducing smoking related risks (88.4%) and that abstinence from all nicotine should not be the only goal discussed with smokers with SMI (77.9%). Many respondents were unsure about the safety (56.9%) and efficacy (39.3%) of e-cigarettes. Practitioners trained in smoking cessation were more likely (OR: 2.9, CI: 1.5-5.9) to help their clients to stop smoking. Community mental health practitioners (OR: 0.3, CI: 0.1-0.9) and practitioners who were current smokers (OR: 0.3, CI: 0.1-0.9) were less likely to adhere to the 5As of smoking cessation intervention. The results of this study emphasize the importance and need for providing smoking cessation training to mental health practitioners especially community mental health practitioners.

Intervention With Brief Cessation Advice Plus Active Referral for Proactively Recruited Community Smokers: A Pragmatic Cluster Randomized Clinical Trial

IMPORTANCE

Most smoking cessation (SC) clinics are costly, passive, and underused.

OBJECTIVE

To compare the SC effect of a combined intervention involving brief, model-guided SC advice plus active referral to SC services (active referral group) with those of brief, model-guided SC advice only (brief advice group) and general SC advice only (control group).

DESIGN, SETTING, AND PARTICIPANTS

A single-blind, 3-arm, pragmatic cluster randomized clinical trial was conducted including 1226 adult daily smokers in the general Hong Kong community proactively recruited to participate in the Quit-to-Win Contest held in 2015. The study was conducted from June 20 to September 24, 2015. Participants were randomly allocated to the active referral (n = 402), brief advice (n = 416), and control (n = 408) groups. Intention-to-treat analysis was used.

INTERVENTIONS

Brief telephone counseling was offered to the active referral and brief advice groups at 1 and 2 months. Interventions were delivered by SC ambassadors who had undergone a short training period.

MAIN OUTCOMES AND MEASURES

The primary outcome was the self-reported past 7-day point prevalence of abstinence (PPA) at 6 months. The secondary outcomes were carbon monoxide level-validated abstinence, smoking reduction, and SC service use.

RESULTS

Participants included 991 (80.8%) men; mean (SD) age was 42.0 (14.8) years. The response rate was 68.2% at 3 and 72.3% at 6 months. The corresponding PPAs were 18.9% and 17.2% in the active referral group-higher than in the brief advice (8.9% and 9.4%; both P ≤ .001) or control (14.0% and 11.5%; P = .03 at 6 months) groups. Compared with the other 2 groups, the active referral group had significantly higher validated abstinence rates (10.2% at 3 months and 9.0% at 6 months, all P < .05) with odds ratios of 2.84 (95% CI, 1.57-5.15) and 2.61 (95% CI, 1.46-4.68) at 3 months, and 1.85 (95% CI, 1.06-3.23) and 1.81 (95% CI, 1.04-3.16) at 6 months in the brief advice and control groups, respectively. The SC service use rate was significantly higher in the active referral group (25.1%) than in either brief advice (2.4%) or control (3.4%) groups at 6 months (P < .001).

CONCLUSIONS AND RELEVANCE

An intervention involving brief advice and active referral delivered to smokers in the community by volunteers can increase quitting in places where SC services are available but underused.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02539875.

Financial Stress and Smoking within a Large Sample of Socially Disadvantaged Australians

Financial stress is associated with fewer quit attempts and higher relapse rates. This study aimed to compare financial stress among smokers, ex-smokers and never smokers in a highly socioeconomically disadvantaged sample. The study also aimed to determine whether specific indicators of financial stress differ according to smoking status. Adult clients seeking welfare assistance from two Social and Community Service Organisation sites in New South Wales, Australia, were invited to complete a cross-sectional survey between March 2012 and December 2013. Responses to a financial stress scale, smoking status and demographics were collected. Linear and logistic regression modelling was used to examine associations between smoking status and financial stress. A total of 1463 participants completed the survey. Current smokers had significantly higher total financial stress scores than ex-smokers and non-smokers respectively. Current smokers also had higher odds of severe financial stress indicators, such as going without meals (Odds Ratio = 2.2 and 2.0), than both non-smokers and ex-smokers. Even among a highly socioeconomically disadvantaged sample with high levels of financial stress, smoking status further exacerbates experiences of deprivation. Given the relationship between financial stress, socioeconomic disadvantage and difficulty quitting, it is important to provide enhanced cessation support to smokers experiencing financial stress.

Stuck in the catch 22: attitudes towards smoking cessation among populations vulnerable to social disadvantage

AIM

To explore how smoking and smoking cessation is perceived within the context of disadvantage, across a broad cross-section of defined populations vulnerable to social disadvantage.

DESIGN

Qualitative focus groups with participants recruited through community service organizations (CSO).

SETTING

Metropolitan and regional settings in Queensland, Australia. Focus groups were held at the respective CSO facilities.

PARTICIPANTS

Fifty-six participants across nine focus groups, including people living with mental illness, people experiencing or at risk of homelessness (adult and youth populations), people living with HIV, people living in a low-income area and Indigenous Australians.

MEASUREMENTS

Thematic, in-depth analysis of focus group discussions. Participant demographic information and smoking history was recorded.

FINDINGS

Smoking behaviour, smoking identity and feelings about smoking were reflective of individual circumstances and social and environmental context. Participants felt 'trapped' in smoking because they felt unable to control the stressful life circumstances that triggered and sustained their smoking. Smoking cessation was viewed as an individual's responsibility, which was at odds with participants' statements about the broader factors outside of their own control that were responsible for their smoking.

CONCLUSION

Highly disadvantaged smokers' views on smoking involve contradictions between feeling that smoking cessation involves personal responsibility, while at the same time feeling trapped by stressful life circumstances. Tobacco control programmes aiming to reduce smoking among disadvantaged groups are unlikely to be successful unless the complex interplay of social factors is carefully considered.

Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need?

In Australia and New Zealand, population groups who experience social disadvantage smoke at much higher rates than the general population. As there are limited data specific to these groups regarding the success of nicotine replacement therapy for smoking cessation, this commentary will provide an overview of the relevant international literature supplemented with observational data relevant to the policy contexts in Australia and New Zealand. [Paul C, Wolfenden L, Tzelepis F, Yoong S, Bowman J, Wye P, Sherwood E, Rose S, Wiggers J. Nicotine replacement therapy as a smoking cessation aid among disadvantaged smokers: What answers do we need? Drug Alcohol Rev 2016;35:785-789].

Comparing socially disadvantaged smokers who agree and decline to participate in a randomised smoking cessation trial

OBJECTIVES

This study examined sociodemographic, smoking and psychosocial characteristics associated with consent to participate in a smoking cessation trial for socially disadvantaged smokers.

DESIGN

Baseline data were collected prior to seeking consent for the Call it Quits, a randomised controlled trial.

SETTING

An Australian social and community service organisation. Sociodemographic, smoking and psychosocial characteristics were compared between smokers who agreed or declined to participate.

PARTICIPANTS

Of the 584 smokers invited to participate, 431 (74%) consented and 153 (26%) declined.

RESULTS

Logistic regression modelling indicates the ORs of participation were twice as high for those reporting 'high' motivation to quit compared to the 'moderate' motivation group, and five times higher than the 'low' motivation group (p=0.007). The ORs of consenting were higher for those with a preference for gradual reduction in cigarettes in quit attempts compared with 'no preference'. The ORs were lower for those reporting 'don't know' regarding their enjoyment of smoking compared to 'not at all' enjoying smoking, and reporting that fewer of their family or friends smoked compared to 'most or all'.

CONCLUSIONS

This study is the first to examine the characteristics of socially disadvantaged smokers who consent or decline to participate in a smoking cessation trial. Low-income smokers who are motivated to quit, are not enjoying smoking, had family or friends who smoked, and who are interested in gradual cessation approaches may be more likely to participate in a smoking cessation trial.

TRIAL REGISTRATION NUMBER

ISRCTN85202510.

Smoking Cessation among Low-Socioeconomic Status and Disadvantaged Population Groups: A Systematic Review of Research Output

Background: Smoking cessation research output should move beyond descriptive research of the health problem to testing interventions that can provide causal data and effective evidence-based solutions. This review examined the number and type of published smoking cessation studies conducted in low-socioeconomic status (low-SES) and disadvantaged population groups. Methods: A systematic database search was conducted for two time periods: 2000–2004 (TP1) and 2008–2012 (TP2). Publications that examined smoking cessation in a low-SES or disadvantaged population were coded by: population of interest; study type (reviews, non-data based publications, data-based publications (descriptive, measurement and intervention research)); and country. Intervention studies were coded in accordance with the Cochrane Effective Practice and Organisation of Care data collection checklist and use of biochemical verification of self-reported abstinence was assessed. Results: 278 citations were included. Research output (i.e., all study types) had increased from TP1 27% to TP2 73% (χ² = 73.13, p < 0.001), however, the proportion of data-based research had not significantly increased from TP1 and TP2: descriptive (TP1 = 23% vs. TP2 = 33%) or intervention (TP1 = 77% vs. TP2 = 67%). The proportion of intervention studies adopting biochemical verification of self-reported abstinence had significantly decreased from TP1 to TP2 with an increased reliance on self-reported abstinence (TP1 = 12% vs. TP2 = 36%). Conclusions: The current research output is not ideal or optimal to decrease smoking rates. Research institutions, scholars and funding organisations should take heed to review findings when developing future research and policy.

Changing low income smokers' beliefs about tobacco dependence treatment

This field study tested an intervention that challenged beliefs about the effectiveness of various quit methods held by Salvation Army client smokers from two urban locations (N = 245). Data (surveys administered immediately after and one month post-intervention) were collected 2009-2010 and analyzed using primarily χ(2) and t-tests. The intervention changed client perceptions about the effectiveness of quitting methods. Compared to no-intervention controls, intervention participants reported significantly greater smoking reduction and greater likelihood of contacting the Wisconsin Tobacco Quit Line. Study implications/limitations are discussed and future research directions noted. This research was supported by grant UL1TR000427 from the Clinical and Translational Science Award (CTSA) program of the National Center for Advancing Translational Sciences, NIH.

A group based smoking cessation pilot programme for community mental health clients in Sydney

Introduction: This article describes the process and evaluation of a smoking cessation support programme for mental health clients in Sydney.

Aim: The objective of the study was to assess a group-based smoking cessation support model for community mental health clients.

Methods: Two community mental health services participated; 29 clients received free NRT products and weekly education for 12 weeks on: effects of smoking, nicotine dependence, NRT use, withdrawal process and the benefits of quitting. Evaluation included face-to-face interviews, telephone or postal survey using a semi-structured questionnaire.

Results: The baseline (n = 29) and follow-up (n = 14) surveys showed reduction in the number of cigarettes (30 to 21) smoked a day (55% vs. 36%). At one month 47% (n = 19) were confident about stopping smoking permanently whereas 19% (n = 14) reported the same after six months. Participants reported concerns of health effects, illness, physical symptoms (77% n = 27) and financial cost (93% n = 27) were the motivating factors in quitting. None of the findings was statistically significant.

Conclusions: Community based interventions to address the rate of smoking in this group is needed. Financial and health benefits can be used as motivating factors, and integration of smoking cessation assistance in treatment and rehabilitation of mental health consumers would be useful.

Smoking, mental illness and socioeconomic disadvantage: analysis of the Australian National Survey of Mental Health and Wellbeing

BACKGROUND

High rates of smoking and lower rates of smoking cessation are known to be associated with common mental disorders such as anxiety and depression, and with individual and community measures of socioeconomic status. It is not known to what extent mental illness and socioeconomic status might be jointly associated with smoking behaviour. We set out to examine the relationship between mental illness, measures of socioeconomic disadvantage and both current smoking and smoking cessation rates.

METHODS

We used data from the 2007 Australian National Survey of Mental Health and Wellbeing to examine the relationship between mental illness, socioeconomic status and both current smoking and smoking cessation. We used cross-classified tables and logistic regression to examine the relationship between psychosocial and sociodemographic predictors and current smoking. We also used proportional hazards regression to examine the relationship between the factors and smoking cessation.

RESULTS

Both mental illness and socioeconomic status were independently associated with current smoking and with lower likelihood of smoking cessation, with gradients in smoking by mental health status being observed within levels of socioeconomic indicators and vice versa. Having a mental illness in the past 12 months was the most prevalent factor strongly associated with smoking, affecting 20.0% of the population, associated with increased current smoking (OR 2.43; 95% CI: 1.97-3.01) and reduced likelihood of smoking cessation (HR: 0.77; 95% CI: 0.65-0.91).

CONCLUSIONS

The association between mental illness and smoking is not explained by the association between mental illness and socioeconomic status. There are strong socioeconomic and psychosocial gradients in both current smoking and smoking cessation. Incorporating knowledge of the other adverse factors in smokers' lives may increase the penetration of tobacco control interventions in population groups that have historically benefitted less from these activities.

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

An RCT protocol of varying financial incentive amounts for smoking cessation among pregnant women

Background

Smoking during pregnancy is harmful to the unborn child. Few smoking cessation interventions have been successfully incorporated into standard antenatal care. The main aim of this study is to determine the feasibility of a personal financial incentive scheme for encouraging smoking cessation among pregnant women.

Design

A pilot randomised control trial will be conducted to assess the feasibility and potential effectiveness of two varying financial incentives that increase incrementally in magnitude ($20 vs. $40AUD), compared to no incentive in reducing smoking in pregnant women attending an Australian public hospital antenatal clinic.

Method

Ninety (90) pregnant women who self-report smoking in the last 7 days and whose smoking status is biochemically verified, will be block randomised into one of three groups: a. No incentive control group (n=30), b. $20 incremental incentive group (n=30), and c. $40 incremental incentive group (n=30). Smoking status will be assessed via a self-report computer based survey in nine study sessions with saliva cotinine analysis used as biochemical validation. Women in the two incentive groups will be eligible to receive a cash reward at each of eight measurement points during pregnancy if 7-day smoking cessation is achieved. Cash rewards will increase incrementally for each period of smoking abstinence.

Discussion

Identifying strategies that are effective in reducing the number of women smoking during pregnancy and are easily adopted into standard antenatal practice is of utmost importance. A personal financial incentive scheme is a potential antenatal smoking cessation strategy that warrants further investigation.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) number: ACTRN12612000399897

What has fairness got to do with it? Tackling tobacco among Australia's disadvantaged

ISSUE

While population wide smoking rates are falling steadily the rates remain high among the disadvantaged. The future we face is one where the differentials in smoking rates will continue to widen and will flow through to increased health inequalities.

APPROACH

How best to reduce smoking rates among the disadvantaged? Alongside existing population level initiatives and social policy initiatives is an urgent need for a targeted, comprehensive approach that acknowledges the serious impact of smoking on the disadvantaged. In 2006 Cancer Council NSW embarked on a statewide, multi-component Tackling Tobacco Program to encourage and support non-government social and community services to address smoking among their clients.

KEY FINDINGS

Tackling Tobacco Program results have shown that the 1600 staff from 400 organisations trained to provide smoking care can attain the knowledge and confidence to address tobacco and that clients are very receptive to receiving quit support from them. Improvements in quality of life for clients who do quit have been encouraging and the Tackling Tobacco Program has challenged assumptions and attitudes that disadvantaged people are uninterested and unable to quit.

IMPLICATIONS

Alongside population and social policy approaches must be a serious investment in tackling smoking among the disadvantaged.

CONCLUSIONS

Tackling Tobacco Program is an innovative example of how to engage disadvantaged smokers, de-normalise smoking and encourage and support quitting using familiar settings. Engaging Australia's large network of social and community services as allies in this work should be vigorously pursued.

Assessing smoking status in disadvantaged populations: is computer administered self report an accurate and acceptable measure?

Background

Self report of smoking status is potentially unreliable in certain situations and in high-risk populations. This study aimed to determine the accuracy and acceptability of computer administered self-report of smoking status among a low socioeconomic (SES) population.

Methods

Clients attending a community service organisation for welfare support were invited to complete a cross-sectional touch screen computer health survey. Following survey completion, participants were invited to provide a breath sample to measure exposure to tobacco smoke in expired air. Sensitivity, specificity, positive predictive value and negative predictive value were calculated.

Results

Three hundred and eighty three participants completed the health survey, and 330 (86%) provided a breath sample. Of participants included in the validation analysis, 59% reported being a daily or occasional smoker. Sensitivity was 94.4% and specificity 92.8%. The positive and negative predictive values were 94.9% and 92.0% respectively. The majority of participants reported that the touch screen survey was both enjoyable (79%) and easy (88%) to complete.

Conclusions

Computer administered self report is both acceptable and accurate as a method of assessing smoking status among low SES smokers in a community setting. Routine collection of health information using touch-screen computer has the potential to identify smokers and increase provision of support and referral in the community setting.

A survey of smoking prevalence and interest in quitting among social and community service organisation clients in Australia: a unique opportunity for reaching the disadvantaged

Background

Social and community service organisations (SCSOs) are non-government, not-for-profit organisations that provide welfare services to disadvantaged individuals. SCSOs hold considerable potential for providing smoking cessation support to disadvantaged smokers. This study aimed to establish the prevalence of smoking, interest in quitting and interest in receiving cessation support amongst clients accessing SCSOs.

Methods

Clients seeking financial or material assistance from three SCSOs in NSW, Australia, between February and October 2010 were invited to complete a 60-item general health touch screen computer survey. This included questions about smoking status, past quit attempts and interest in receiving support to quit smoking from SCSO staff.

Results

A total of 552 clients were approached to participate during the study period, of which 383 provided consent and completed the survey (69% consent rate). Daily smoking was reported by 53.5% of participants. Occasional smoking (non-daily smoking) was reported by a further 7.9% of participants. Most participants had tried to quit smoking in the past (77%) and had made an average of two quit attempts (SD = 3.2) lasting longer than 24 hours in the previous 12 months. More than half of all participants (52.8%) reported that they would like help from SCSO staff to quit smoking. For those interested in receiving help, the preferred types of help were access to free NRT (77%), cash rewards (52%) and non-cash rewards (47%) for quitting, and to receive support and encouragement from SCSO staff to quit (45%).

Conclusions

Smoking rates among clients accessing SCSO are substantially higher than the general population rate of 15.1%. A substantial proportion of clients are interested in quitting and want support from the SCSO to do so.

A systematic review and meta-analysis of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups

AIMS

A systematic review and meta-analysis was conducted to assess the methodological quality and effectiveness of behavioural smoking cessation interventions targeted at six disadvantaged groups; the homeless, prisoners, indigenous populations, at-risk youth, individuals with low socio-economic status and individuals with a mental illness.

METHODS

Medline, EMBASE, the Cochrane Library and PsycInfo databases were searched using MeSH and keywords for studies conducted in developed countries prior to October 2010. Included studies were assessed for methodological quality. A DerSimonian and Laird random effects meta-analysis was conducted where possible to explore the effectiveness of interventions for the different subgroups. A narrative review was conducted for studies unable to be included in the meta-analysis. Outcomes examined were abstinence rates at short-term (up to 3 months) and long-term (6 months or the longest) follow-up.

RESULTS

Thirty-two relevant studies were identified. The majority (n = 20) were rated low in methodological quality. Results of the meta-analysis showed a significant increase in cessation for behavioural support interventions targeted at low-income female smokers at short-term follow-up [relative risk (RR) 1.68, confidence interval (CI) 1.21-2.33], and behavioural support interventions targeted at individuals with a mental illness at long-term follow-up (RR 1.35, CI 1.01-1.81). Results of the narrative review showed several promising interventions that increased cessation rates at 6-month or longer follow-up.

CONCLUSIONS

Few well-controlled trials have examined the most effective smoking cessation strategies for highly disadvantaged groups, especially among the homeless, indigenous smokers and prisoners. The use of behavioural smoking cessation interventions for some socially disadvantaged groups appears promising; however, overall findings are inconsistent. Further research is needed to establish the most effective interventions for vulnerable high-risk groups. Special attention should be given to increasing sample size and power, and to sound evaluation methodology to overcome methodological limitations of conducting research with these high-risk groups.

Developing cessation interventions for the social and community service setting: a qualitative study of barriers to quitting among disadvantaged Australian smokers

Background

Smoking rates remain unacceptably high among individuals who are socially disadvantaged. Social and community service organisations (SCSO) are increasingly interested in providing smoking cessation support to clients, however little is known about the best way to assist disadvantaged smokers to quit in this setting. This study aimed to explore barriers and facilitators to quitting within the conceptual framework of the PRECEDE model to identify possible interventions appropriate to the social and community service setting.

Methods

Semi-structured focus groups were conducted with clients attending five community welfare organisations located in New South Wales, Australia. Thirty-two clients participated in six focus groups. A discussion guide was used to explore the barriers and facilitators to smoking and smoking cessation including: current smoking behaviour, motivation to quit, past quit attempts, barriers to quitting and preferences for cessation support. Focus groups were audio-taped, transcribed and analysed using thematic analysis techniques.

Results

Participants were current smokers and most expressed a desire to quit. Factors predisposing continued smoking included perceived benefits of smoking for stress relief, doubting of ability to quit, fear of gaining weight, and poor knowledge and scepticism about available quit support. The high cost of nicotine replacement therapy was a barrier to its use. Continual exposure to smoking in personal relationships and in the community reinforced smoking. Participants expressed a strong preference for personalised quit support.

Conclusions

Disadvantaged smokers in Australia express a desire to quit smoking, but find quitting difficult for a number of reasons. SCSOs may have a role in providing information about the availability of quit support, engaging disadvantaged smokers with available quit support, and providing personalised, ongoing support.