Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: a systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis

Reintroducing face-to-face support alongside remote support to form a hybrid stop smoking service in England: a formative mixed methods evaluation

BACKGROUND

During the COVID-19 pandemic, United Kingdom (UK) stop smoking services had to shift to remote delivery models due to social distancing regulations, later reintroducing face-to-face provision. The "Living Well Smokefree" service in North Yorkshire County Council adopted a hybrid model offering face-to-face, remote, or a mix of both. This evaluation aimed to assess the hybrid approach's strengths and weaknesses and explore potential improvements.

METHODS

Conducted from September 2022 to February 2023, the evaluation consisted of three components. First, qualitative interviews involved 11 staff and 16 service users, analysed thematically. Second, quantitative data from the QuitManager system that monitored the numbers and proportions of individuals selecting and successfully completing a 4-week quit via each service option. Third, face-to-face service expenses data was used to estimate the value for money of additional face-to-face provision. The qualitative findings were used to give context to the quantitative data via an "expansion" approach and complementary analysis.

RESULTS

Overall, a hybrid model was seen to provide convenience and flexible options for support. In the evaluation, 733 individuals accessed the service, with 91.3% selecting remote support, 6.1% face-to-face, and 2.6% mixed provision. Remote support was valued by service users and staff for promoting openness, privacy, and reducing stigma, and was noted as removing access barriers and improving service availability. However, the absence of carbon monoxide monitoring in remote support raised accountability concerns. The trade-off in "quantity vs. quality" of quits was debated, as remote support reached more users but produced fewer carbon monoxide-validated quits. Primarily offering remote support could lead to substantial workloads, as staff often extend their roles to include social/mental health support, which was sometimes emotionally challenging. Offering service users a choice of support options was considered more important than the "cost-per-quit". Improved dissemination of information to support service users in understanding their options for support was suggested.

CONCLUSIONS

The hybrid approach allows smoking cessation services to evaluate which groups benefit from remote, face-to-face, or mixed options and allocate resources accordingly. Providing choice, flexible provision, non-judgmental support, and clear information about available options could improve engagement and match support to individual needs, enhancing outcomes.

Health professional's perception of a smoking cessation intervention among disadvantaged patients participating in a pragmatic randomized trial

INTRODUCTION

Individuals who have a low socio-economic position (SEP) are more likely to smoke and face greater barriers to quitting tobacco. However, the effectiveness of tailored interventions has been limited probably due to specific challenges relative to this population. We conducted a mixed-method study to better understand health professionals' perceptions and barriers when implementing a preference-based smoking cessation (SC) intervention among disadvantaged smokers.

METHODS

A self-administered online questionnaire was sent to health professionals (doctors' and other health professionals specialized in SC) participating in "STOP" a pragmatic multicentre randomized controlled trial. Perceptions regarding patient eligibility, the doctor-patient relationship, general study organization, and satisfaction were measured.

RESULTS

Twenty-eight STOP study investigators responded. Health professionals prioritize smoking cessation for disadvantaged patients, but face challenges in approaching and following them. A research intervention providing cessation tools based on preference was deemed useful but generally undermined by time constraints. Health professionals' preconceptions regarding patients in low SEP having other "pressing problems" which might be exacerbated by quitting smoking were also identified. Further, participation in a research intervention was perceived as not satisfactory due to workload and lack of time.

CONCLUSION

Our results highlight general barriers inherent to implementing pragmatic trials. They also present specific challenges in smoking cessation trials among disadvantaged population, essential to advance equity in tobacco control.

Hidradenitis suppurativa and social disadvantage: A nationwide administrative data study of the French hospitalized population

BACKGROUND

A lower socioeconomical status (SES) has been reported in patients suffering from hidradenitis suppurative (HS). However, limitations in the available studies prevent drawing definitive conclusions.

OBJECTIVES

The objective of this study was to assess the SES of HS patients using a specific SES indicator, the French DEPrivation index (FDep), specifically designed and validated for the French population.

METHODS

This cross-sectional cohort study compared the HS hospitalized population with the general hospitalized population without HS. Data were extracted from the French national hospital discharge database, an exhaustive database on all reimbursed hospital stay in the country with a rolling 10-year history (2012-2021). We included all patients aged 7-75 years with at least one stay in a French hospital. A 1:40 propensity score matching, adjusted for age, sex, smoking status and obesity, was performed to create 2 groups of comparable patients. Subgroup analysis was done in the minor (7-17 years) and major (25-75 years) populations independently.

RESULTS

In the overall population, we identified 33,880 patients with HS and 24,445,337 patients without HS. After propensity score matching, logistic regression showed a significant association between HS and social disadvantage. There is a 22.5% increased risk of developing HS for individuals being in quintile 5 (the most disadvantaged quintile) versus quintile 1 (the least disadvantaged quintile) (p < 0.0001). After propensity score matching, the logistic regression showed no association between HS and social disadvantage in the 7-17 subgroup. In this minor population, an association between HS and social disadvantage was observed when propensity score matching was performed on age and sex only.

CONCLUSIONS

We demonstrate a significant association between HS and low SES in the adult population. In children between 7 and 17, low SES was associated with obesity and tobacco consumption, but not with HS when the populations were matched on these confounding factors.

Who benefits from alcohol screening and brief intervention? A mini-review on socioeconomic inequalities with a focus on evidence from the United States

Alcohol-attributable mortality contributes to growing health inequalities. Addressing hazardous alcohol use and alcohol use disorders through alcohol screening and brief intervention is therefore a promising public health strategy to improve health equity. In this narrative mini-review, we discuss the extent to which socioeconomic differences exist in the alcohol screening and brief intervention cascade, highlighting the example of the United States. We have searched PubMed to identify and summarize relevant literature addressing socioeconomic inequalities in (a) accessing and affording healthcare, (b) receiving alcohol screenings, and/or (c) receiving brief interventions, focusing predominantly on literature from the Unites States. We found evidence for income-related inequalities in access to healthcare in the United States, partly due to inadequate health insurance coverage for individuals with low socioeconomic status. Alcohol screening coverage appears to be generally very low, as is the probability of receiving a brief intervention when indicated. However, research suggests that the latter is more likely to be provided to individuals with low socioeconomic status than those with high socioeconomic status. Individuals with low socioeconomic status also tend to benefit more from brief interventions, showing greater reductions in their alcohol use. Once access to and affordability of healthcare is ensured and high coverage of alcohol screening is achieved for all, alcohol screening and brief interventions have the potential to enhance health equity by reducing alcohol consumption and alcohol-related health harms.

Use of e-Cigarettes and Attendance at Stop Smoking Services: A Population Survey in England

Little is known about whether e-cigarette use influences tobacco smokers' decisions around other smoking cessation options, including the most effective one available: stop smoking service (SSS) attendance. Our repeat cross-sectional survey therefore assessed associations between use of e-cigarettes with past and planned future uptake of SSSs. Nicotine replacement therapy (NRT) use was also assessed as a comparator. Participants were drawn from the Smoking Toolkit Study, a nationally representative, validated, face-to-face survey. Data were aggregated on 2139 English adults reporting current smoking of cigarettes or other tobacco products. Multivariable logistic regression was used to adjust for potential confounders. Results showed dual users of combustible tobacco and e-cigarettes were more likely than other smokers to report having accessed SSSs in the past (AOR 1.43, 95% CI 1.08 to 1.90) and intending to take up these services in future (AOR 1.51, 95% CI 1.14 to 2.00). Dual users of combustible tobacco and NRT showed similar associations. Secondary objectives provided evidence on key psychosocial factors that influenced smokers' decision-making in this area. In summary, despite speculation that e-cigarette use might deter smokers from accessing SSSs, our study found dual users of tobacco and e-cigarettes were more likely to report uptake of such services, compared to smokers not using e-cigarettes.

Socio-economic deprivation and cancer incidence in England: Quantifying the role of smoking

BACKGROUND

More deprived populations typically experience higher cancer incidence rates and smoking prevalence compared to less deprived populations. We calculated the proportion of cancer cases attributable to smoking by socio-economic deprivation in England and estimated the impact smoking has on the deprivation gap for cancer incidence.

METHODS

Data for cancer incidence (2013-2017), smoking prevalence (2003-2007) and population estimates (2013-2017) were split by sex, age-group and deprivation quintile. Relative risk estimates from meta-analyses were used to estimate the population attributable fraction (PAF) for 15 cancer types associated with smoking. The deprivation gap was calculated using age-specific incidence rates by deprivation quintile.

RESULTS

Smoking-related cancer PAFs in England are 2.2 times larger in the most deprived quintile compared to the least deprived quintile (from 9.7% to 21.1%). If everyone had the same smoking prevalence as the least deprived quintile, 20% of the deprivation gap in cancer incidence could have been prevented. If nobody smoked, 61% of the deprivation gap could have been prevented.

CONCLUSIONS

The majority of the deprivation gap in cancer incidence could have been prevented in England between 2013-2017 if nobody had smoked. Policy makers should ensure that tobacco control policies reduce overall smoking prevalence by tackling smoking inequalities.

The Frequency of Tobacco Smoking and E-Cigarettes Use among Primary Health Care Patients-The Association between Anti-Tobacco Interventions and Smoking in Poland

The aim of this study was to assess the prevalence of smoking and e-cigarette use among primary care patients during the COVID-19 pandemic and to assess the frequency of minimal anti-tobacco interventions by family doctors. A cross-sectional study was conducted from January 2020 to December 2021 encompassing 896 patients over 18 years of age who used primary health care in the city of Lodz, Poland. In total, 21.2% of the respondents were smokers, 11.6% were e-cigarette users, and 7.3% dual users. In addition, 68.4% of smokers had been asked about smoking, while 62.9% of non-smokers and 33.7% of smokers were advised to quit smoking; furthermore, 71.1% of e-cigarette users and 72.3% of dual users were asked about tobacco use, and 17.3% and 21.5%, respectively, had been advised to quit smoking. Multivariate logistic regression analysis found men and alcohol users to receive more minimal anti-tobacco advice than women and non-alcohol users (OR = 1.46; p < 0.05 and OR = 1.45; p < 0.05), socio-demographic and health correlates did not increase the chances of obtaining minimal anti-tobacco interventions among smokers. People with a medium level of education had a higher chance of receiving minimal anti-tobacco intervention from their family doctor when using e-cigarettes and when they were dual users (OR = 2.06; p < 0.05 and OR = 2.51; p < 0.05). Smokers were less likely to receive minimal anti-tobacco interventions than reported in previous studies. Measures should be implemented to increase the minimum interventions provided by GPs in their daily work among all patients, not only those who use tobacco. Non-smokers should be encouraged to abstain.

Reducing lifestyle risk behaviours in disadvantaged groups in high-income countries: A scoping review of systematic reviews

High prevalence of risk behaviours may exacerbate existing poor health in disadvantaged groups. We aimed to identify and bring together systematic reviews with a focus on reducing risk behaviours in disadvantaged groups and highlight where evidence is lacking. We searched MEDLINE and Embase up to October 2020, with supplementary searching in Epistemonikos and Health Systems Evidence. We included systematic reviews that reported behavioural outcomes and targeted smoking, excessive alcohol use, unhealthy diet, or physical inactivity in groups with the following characteristics: low income or low socio-economic status (SES), unemployed people, homeless people, care leavers, prisoners, refugees or asylum seeker, Gypsies, Travellers, or Roma, people with learning disabilities and people living in disadvantaged areas. Reviews that included primary studies from any high-income country were eligible. Reviews were mapped based on the disadvantaged group(s) and behaviour(s) targeted. Ninety-two reviews were included, with the majority (n = 63) focusing on people with low income or low SES. We identified gaps in the evidence for care leavers; Gypsies, Travellers, and Roma and limited evidence for refugees and unemployed people. Few reviews targeted alcohol use. There was limited evidence on barriers and facilitators to behaviour change. This suggests there is insufficient evidence to inform policy and practice and new reviews or primary studies may be required.

Socioeconomic inequalities in secondhand smoke exposure before, during and after implementation of Quebec's 2015 'An Act to Bolster Tobacco Control'

BACKGROUND

To better understand whether tobacco control policies are associated with changes in secondhand smoke (SHS) exposure across socioeconomic groups, we monitored differences in socioeconomic inequalities in SHS exposure in households and private vehicles among youth and adults before, during and after adoption of Quebec's 2015 An Act to Bolster Tobacco Control.

METHODS

Using data from the Canadian Community Health Survey, we examined the prevalence of daily exposure to SHS in households and private vehicles among youth (ages 12 to 17) and adults (ages 18+) across levels of household education and income (separately) in 2013/2014, 2015/2016 and 2017/2018. We tested differences in the magnitude of differences in outcomes over time across education and income categories using logistic models with interaction terms, controlling for age and sex.

RESULTS

We detected inequalities in SHS exposure outcomes at each time point, most markedly at home among youth (OR of SHS exposure among youth living in the 20% poorest households vs the 20% richest=4.9, 95% CI 2.7 to 6.2). There were decreases in SHS exposure in homes and cars in each education/income group over time. The magnitude of inequalities in SHS exposure in homes and cars, however, did not change during this period.

CONCLUSIONS

The persistence of socioeconomic inequalities in SHS exposure despite implementation of new tobacco control laws represents an increasingly worrisome public health challenge, particularly among youth. Policymakers should prioritise the reduction of socioeconomic inequalities in SHS exposure and consider the specific needs of socioeconomically disadvantaged populations in the design of future legislation.

Group Support for Smoking Cessation: Importance of the Smoker's Choice for Better Outcomes

Smoking cessation method effectiveness is discussed among socially disadvantaged smokers. Our aim was to measure real-life effectiveness of the choice of a multi-component group intervention in comparison with individual usual care. We report an observational study (N = 100). Disadvantaged smokers were screened with a validated tool. We designed a multi-component structured behavioural group intervention, delivered in weekly group sessions during 6 weeks. Usual care consisted of individual visits. Both groups received free nicotine replacement therapy. We observed 33 smokers participating in the group intervention, while 67 received usual care. Abstinence at 6 weeks was 24.2% (n = 8) in the group intervention versus 11.9% (n = 8) in usual care (p = .115). Also, 36.4% (n = 12) of group intervention patients had reduced their cigarette consumption versus 16.4% (n = 11) in usual care (p = .026). In addition, 6.1% (n = 2) dropped out of group versus 31.3% (n = 21) in usual care (p = .005). Finally, 6 months after their first visit, 15.2% (n = 5) of group intervention patients and 4.5% (n = 3) in usual care were abstinent (p = .111). Group intervention choice versus usual care might facilitate smoking abstinence, reduction, and follow-up adherence.

Understanding willingness to access and experiences of NHS Stop Smoking Services: a qualitative systematic review with meta-aggregation synthesis

OBJECTIVES

NHS Stop Smoking Services (NHS-SSS) have been available in the United Kingdom (UK) since 2000. The service has proven to be effective, however uptake remains below aspirations. Understanding people's willingness and reasons for accessing and engaging with NHS-SSS is, therefore, important. The aim of this systematic review is to summarise the findings from qualitative research to understand people's views, perceptions and willingness to access NHS-SSS.

STUDY DESIGN

Qualitative systematic review with meta-aggregation synthesis.

METHODS

Four electronic databases were searched for published qualitative studies, from Jan 2000 to Jan 2020. Following the screening, data extraction and quality assessment, data synthesis was conducted using meta-aggregation based on a patient-centred theoretical framework. We explored five 'demand-side' dimensions of service accessibility: the ability to perceive, seek, reach, pay and engage. Confidence in the synthesised findings relating to dependability and credibility was established using CONQual.

RESULTS

Seventeen studies were included in the review. Twelve categories emerged, contributing to five synthesised statements, all with a CONQual rating of moderate confidence. Access and willingness to use NHS-SSS were found to be related to an individual's readiness to perceive that smoking is a problem for which a solution should be sought, their ability to seek a perceived effective treatment, to conveniently reach NHS-SSS, their perceptions around associated costs and tailoring care to improve engagement with individuals.

CONCLUSIONS

By using a theoretical framework incorporating healthcare access, this study provides policymakers valuable insights into people's willingness to access these services. Willingness to access NHS-SSS is multifaceted, nuanced and complex. Strategies to promote NHS-SSS uptake should include making services more attractive, relevant and responsive to individual perceptions around smoking and health. Given the higher prevalence of smoking in less affluent socioeconomic groups and in some ethnic minority groups, the importance of having a comprehensive and inclusive tobacco control policy, one that is linguistically and culturally sensitive, cannot be overstated.

Association between income and education with quit attempts, use of cessation aids, and short-term success in tobacco smokers: A social gradient analysis from a population-based cross-sectional household survey in Germany (DEBRA study)

INTRODUCTION

Smoking is more prevalent in smokers from lower compared with higher socioeconomic (SES) groups, but studies are inconsistent regarding underlying mechanisms. We aimed to assess associations between SES indicators and three distinct aspects of the smoking cessation process: attempting to quit; use of evidence-based cessation treatments; and success.

METHODS

We analysed data of 12,161 last-year smokers (i.e., current smokers and recent ex-smokers who quit ≤ 12 months) from 20 waves (June/July 2016 to August/September 2019) of the German Study on Tobacco Use (DEBRA) - a representative household survey. Associations between indicators of SES (income and education) and (1) last-year quit attempts; (2) use of evidence-based cessation treatment or electronic cigarettes during the last attempt; and (3) short-term self-reported abstinence were analysed using multivariable logistic regression, adjusted for potential confounders.

RESULTS

Of all last-years smokers, 18.6% had attempted to quit, of whom 15.2% had successfully stopped. Higher income (OR 0.82, 95%CI = 0.77-0.88 per 1000€) but low vs. high education (OR 0.83, 95%CI = 0.73-0.95) were associated with lower odds of quit attempts. In smokers with quit attempts, higher income but not education was associated with higher odds of using cessation medication (OR 1.31, 95%CI = 1.08-1.59 per 1000 €). Neither income nor education were associated with using behavioural support or success.

CONCLUSIONS

In the German healthcare system without free access to evidence-based cessation therapy, low-income smokers are more likely to make a quit attempt but less likely to use cessation medication than high-income smokers. Equitable access to such medication is crucial to reduce SES-related health disparities.

Mental health and smoking cessation-a population survey in England

BACKGROUND

To reduce inequalities between individuals with and without mental health problems, a better understanding is required of triggers and success of quit attempts among the third of smokers with mental health problems. The aim was to assess whether there are differences by mental health status in (i) triggers for quit attempts, (ii) use of evidence-based support (iii) and quit success.

METHODS

Monthly cross-sectional household surveys of representative samples of the adult population in England. In 2016/2017, 40,831 adults were surveyed; 1956 who had attempted to stop smoking cigarettes in the past year were included. Logistic regressions assessed associations between mental health (ever diagnosis, past-year treatment, past-month distress), triggers, support used and quit success, adjusting for sociodemographic and smoking characteristics.

RESULTS

Concern about future health, current health problems and expense of smoking were the most common triggers overall. For respondents with an ever diagnosis, past-year treatment or serious past-month distress, quit attempts were more frequently triggered by current health problems. Non-evidence-based support and e-cigarettes were used most often, and this did not differ by mental health status. Respondents with an ever diagnosis and moderate or serious distress were less likely to have used non-prescription nicotine replacement therapy (NRT). Respondents with past-year treatment or serious distress were more likely to have used prescription medication/behavioural support. Quit success did not differ by mental health status. Compared with non-evidence-based support, non-prescription NRT conferred no benefit. There was some evidence that prescription medication/behavioural support was beneficial (depending on outcome and adjustment, ORs ranged from 1.46, 95% CI 0.92-2.31, to 1.69, 1.01-2.86). E-cigarettes were associated with higher success rates after adjustment for different indicators of mental health (ORs ranged from 2.21, 1.64-2.98, to 2.25, 1.59-3.18).

CONCLUSIONS

Smokers with mental health problems were more likely to have attempted to quit because of health problems and were more likely to have used gold standard support (medication and behavioural support) than other smokers. E-cigarettes were strongly associated with increased success and were used similarly by those with and without mental health problems, indicating that improved uptake of e-cigarettes for smoking cessation among smokers with mental health problems could help address inequalities.

Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: a systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis

AIM

To assess the impact of UK specialist and primary care-based stop smoking support on socio-economic inequalities in cessation.

METHODS

Systematic review and narrative synthesis, with a national equity analysis of stop smoking services (SSS). Ten bibliographic databases were searched for studies of any design, published since 2012, which evaluated specialist or primary care-based stop smoking support by socio-economic status (SES) or within a disadvantaged group. Studies could report on any cessation-related outcome. National Statistics were combined to estimate population-level SSS reach and impact among all smokers by SES. Overall, we included 27 published studies and three collated, national SSS reports for England, Scotland and Northern Ireland (equivalent data for Wales were unavailable).

RESULTS

Primary care providers and SSS in the United Kingdom were particularly effective at engaging and supporting disadvantaged smokers. Low SES groups were more likely to have their smoking status assessed, to receive general practitioner brief cessation advice/SSS referral and to attempt a quit with SSS support. Although disadvantaged SSS clients were less successful in quitting, increased service reach offset these lower quit rates, resulting in higher service impact among smokers from low SES groups. Interventions that offer tailored and targeted support have the potential to improve quit outcomes among disadvantaged smokers.

CONCLUSIONS

Equity-orientated stop smoking support can compensate for lower quit rates among disadvantaged smokers through the use of equity-based performance targets, provision of targeted services and the development of tailored interventions.